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Supported by grant 48.090.3/2013-1 from the Brazilian National Council for Scientific and Technological Development (CNPq) and by grant 2012/15223-2
from São Paulo Research Foundation (FAPESP).
a
Predoctoral student, Department of Prosthodontics and Periodontology, University of Campinas (UNICAMP), Piracicaba Dental School, São Paulo, Brazil.
b
Predoctoral student, Department of Prosthodontics and Periodontology, University of Campinas (UNICAMP), Piracicaba Dental School, São Paulo, Brazil.
c
Professor, Department of Prosthodontics and Periodontology, University of Campinas (UNICAMP), Piracicaba Dental School, São Paulo, Brazil.
were recruited from elders who were members of the metallic molds, which were completely polymerized for
Brazilian Parkinson Association and elders who sought 16 hours at 65 C. Participants were instructed to masti-
prosthetic treatment at the dental clinic of Piracicaba cate a 3.7 g portion of Optocal in the habitual manner for
Dental School, University of Campinas. Inclusion and 40 strokes24 while a single calibrated operator (G.R.R.)
exclusion criteria are presented in Table 1. counted the cycles. The comminuted particles were
Sample size was estimated on the basis of a previous collected, dried at room temperature for 1 week, then
study,31 and 12 participants were required to detect dif- vibrated in a sieving machine (Bertel Indústria Metal-
ferences with a power b=.8 and a=.05. Considering a úrgica) through a stack of 10 sieves with variably sized
withdrawal rate of 25%, the final sample size was at least mesh (0.5 to 5.6 mm). Materials retained on sieves were
15 volunteers for each group. Because the group with PD weighed on a 0.001 g analytic balance (BEL Engineering),
was composed of elders with neurodegenerative disease, and ME was calculated as the percentage weight of the
more participants were included in view of possible comminuted material that passed through the 2.8 mm
additional withdrawals. Thus, the sample was composed sieve.24
of 17 volunteers per group. During the selection of vol- After baseline evaluations, all participants received
unteers, an endeavor was made to standardize the new CDs and/or RPDs from a single prosthodontist
sample by age, number of remaining teeth in partially (G.R.R.). The RPDs, including major connectors, rests,
dentate participants, and their prostheses characteris- and clasps designed to support the tissues and remaining
tics.30 The group with PD consisted of 17 participants teeth of each participant, were designed according to
(9 men and 8 women; mean age 69.4 ±4.7 years) with a individual anatomic characteristics. All frameworks were
PD diagnosis 6.8 ±3.8 years previously. The control group processed with Co-Cr cast metal (CoCr Alloy DeguDent;
consisted of 17 elders (10 men and 7 women; mean age Dentsply Sirona). Artificial teeth (Biotone; Dentsply
70.7 ±4.7 years). Sirona) were mounted on wax occlusion rims on the RPD
Participants first received general dental treatment frameworks. The prostheses were processed with heat-
according to their individual needs, including basic polymerized acrylic resin (VIPI Cril Plus; VIPI) accord-
periodontal therapy, endodontic treatment, and tooth ing to conventional techniques.20,21 All prostheses were
restoration procedures. Next, all participants underwent fabricated by 1 dental technician. Occlusal denture sup-
baseline assessment of OHRQoL and ME. The baseline port was established through the first molars by using a
assessment was done with the existing removable dental bilateral balanced occlusal scheme. All prostheses were
prosthesis in place or with no prosthesis, depending on adjusted according to individual needs. After 2 months,
whether or not the participant had the dental prosthesis the OHRQoL and ME were reevaluated.
at the baseline period. New CDs and/or RPDs were The data were evaluated by statistical software (SAS
inserted, and after a 2-month adaptation period, v9.3; SAS Institute) (a=.05). Shapiro-Wilk tests were
OHRQoL and ME were reassessed. Because motor used to assess normality. When normality assumptions
symptoms varied in elders with PD (“oneoff” phenom- were met, the values obtained before and after new
enon), participants were evaluated in the morning, 1 prosthesis insertion were compared for each group by
hour after ingestion of levodopa, which is considered to paired t tests. However, when normality assumptions
be a period of good motor function (“on” period).3 The were not met, the Wilcoxon sign tests or Wilcoxon
control group was also evaluated in the morning. signed-rank tests were applied. Comparisons between
The Portuguese version of the Oral Health Impact groups were carried out by t tests when normality as-
Profile (OHIP-49)13 questionnaire, translated and sumptions were met. When normality assumptions were
adapted from English,12 was used to assess OHRQoL. not met, the groups were compared with the Mann-
This questionnaire comprised 49 items across 7 domains: Whitney Wilcoxon tests. For nonparametric assumption
functional limitation; physical pain; psychological in nominal variables, chi-square tests were performed.
discomfort; physical disability; psychological disability;
social disability; and handicap. Participants were
RESULTS
instructed to rate the frequency of each OHIP-49 item on
a 5-point Likert-like scale (4=very often; 3=fairly often; Oral characteristics were normally distributed and
2=occasionally; 1=hardly ever; 0=never). An OHIP-49 showed that the groups were similar across the number
total score was calculated for each participant by sum- of remaining teeth, prostheses type, and prostheses age
ming the item scores. Higher total OHIP-49 scores (P>.05) (Table 2). Normality assumptions were also met
indicate more negative perceptions of the impact of oral for each group at baseline and after the insertion of the
conditions on well-being.12 removable prostheses for the domains of functional
ME was evaluated using Optocal artificial test mate- limitation, physical pain, psychological discomfort,
rial.25 Optocal was prepared by mixing the components25 physical disability, and total OHIP-49. However, a
in a ceramic mortar, then creating cubes (5.6 mm3) in nonparametric distribution was observed for the
Table 2. Oral characteristics of PD and control groups Table 3. Masticatory efficiency (%) and OHIP-49 domains obtained from
PD Control PD and control groups at baseline and after RPI (mean ±SD)
Characteristic Baseline After RPI Baseline After RPI PD Control
No. of teeth 10.0 ±5.2 9.6 ±5.0 8.2 ±4.1 8.2 ±4.1 Characteristic Baseline After RPI Baseline After RPI
Prostheses type Masticatory efficiency 7.0 ±9.8Aa 13.9 ±13.2Ba 13.0 ±11.3Ab 23.9 ±17.2Bb
CD in both jaws 5 (29.4) 6 (35.3) 8 (47.0) 9 (53.0) Functional limitation 23.0 ±9.4Aa 8.8 ±4.3Ba 12.8 ±6.6Ab 5.1 ±3.4Bb
Maxillary CD with 3 (17.6) 4 (23.5) 4 (23.5) 5 (29.4) Physical pain 14.2 ±8.6Aa 4.9 ±5.3Ba 10.5 ±7.1Aa 2.5 ±2.7Ba
mandibular RPD Psychological discomfort 11.3 ±8.7Aa 0.4 ±0.7Ba 6.5 ±6.5Aa 0.8 ±1.3Ba
RPD in both jaws 2 (11.8) 7 (41.2) 0 (0) 3 (17.6) Physical disability 18.2 ±1.3 Aa
3.6 ±4.2 Ba
5.4 ±4.9 Ab
1.9 ±2.3Ba
Only maxillary CD 2 (11.8) NA 2 (11.8) NA Psychological disability 4.4 ±5.8 Aa
0.5 ±1.2 Ba
2.6 ±3.9 Aa
0.1 ±0.4Bb
Only maxillary RPD 4 (23.5) NA 1 (5.9) NA Social disability 2.7 ±6.8 Aa
0.0 ±0.0 Aa
0.9 ±2.1 Aa
0.3 ±0.7Aa
Partially dentate 1 (5.9) NA 2 (11.8) NA Handicap 2.5 ±3.5Aa 0.0 ±0.0Ba 0.0 ±0.0Ab 0.0 ±0.0Aa
without RPD
Total OHIP-49 76.4 ±5.6Aa 18.2 ±13.3Ba 38.7 ±19.6Ab 10.7 ±8.2Ba
Prosthesis age (y)
Maxillary 9.4 ±10.3 NA 12.2 ±14.2 NA OHIP-49, Oral Health Impact Profile; PD, Parkinson disease; RPI, removable prosthesis
insertion. Different uppercase letters indicate differences between baseline and after RPI
Mandibular 7.9 ±6.5 NA 10.1 ±10.6 NA for each group (P<.05). Different lowercase letters indicate differences between PD and
control groups at each time point (P<.05).
PD, Parkinson disease; RPI, removable prosthesis insertion; CD, complete denture; RPD,
removable partial denture; NA, not applicable. Data presented as means ±SD or n (%).
Values for PD and Control not statistically different at baseline (P >.05).
no effects were observed on the social disability or could be that motor impairments caused by PD influ-
handicap domains. These domains may not have affected enced the functional limitation domain because of the
OHRQoL because of a lack of impact on everyday social difficulty in adjusting to the new removable prostheses.
activities; oral health may not negatively affect well-being As a consequence, elders with PD may also have
in controls.12 It is possible that, although OHRQoL experienced greater psychological disability during the
improved after insertion of new removable prostheses, period of adaptation to the new removable prostheses.
control elders had positive perceptions of the impact of Difficulty in adjusting to new prostheses could also
oral conditions on their well-being both at baseline and explain the lower ME in participants with PD compared
after insertion of their removable prosthesis. with controls after insertion of the removable prosthesis.
Controls also showed an improvement in ME after In addition, the rigidity and bradykinesia of PD1 could
insertion of the removable prosthesis. This result sup- explain the impaired ME because increased muscle tone
ports previous studies that reported greater ME after and reduced tongue movement could make transport of
prosthetic rehabilitation in patients with complete and food from the incisor region to the molar region during
partial edentulism.26,27 Oral rehabilitation with new mastication difficult, leading to the loss of bolus forma-
removable prostheses increased the total number of tion3 during Optocal mastication.
teeth, occlusal contact area, and quantity of food particles The quality of the residual alveolar ridge was not
trapped between the teeth.26 As a consequence, reha- registered in the present study. Since the residual alve-
bilitation may have increased food comminution, olar ridge could influence masticatory capacity,26 this
explaining the improved ME in control participants after absent evaluation could be considered as a limitation of
insertion of the new prostheses. this study. In addition, the general dental treatment
At baseline, the group with PD had greater OHIP-49 could also have influenced the present OHRQoL results
scores than controls, revealing a more negative impact of because of its positive impact on oral perception for both
oral condition on OHRQoL, mainly in the domains of PD and control participants. This emphasizes the
functional limitation, physical disability, and handicap. importance of oral health care. In addition, prosthetic
Our results agree with previous studies15,16 that found rehabilitation generally improves the OHRQoL of pa-
negative impacts of oral conditions on OHRQoL in tients, regardless of the type of dental prosthesis.11
participants with PD. Since participants with PD and Studies using OHIP-49 to assess OHRQoL usually
controls had similar oral characteristics at baseline, these include a much larger sample size than the current study.
characteristics may not explain the negative impact of However, the current sample size was sufficient to show
oral condition on OHRQoL in the group with PD. One significant improvement in OHRQoL and ME in both the
explanation could be that PD may cause orofacial PD and control groups.
symptoms in such participants, which may cause diffi- This study was an attempt to investigate mastication
culties in mastication, eating, and pronunciation, thus and OHRQoL during the good motor function time of
reducing well-being. elders with PD and after the ingestion of levodopa
ME was also lower for elders with PD when compared medication. Thus, future studies comparing levodopa
with controls at baseline. This could be because the “on” and “off” periods would be relevant.
neuromuscular control of mastication plays an important
role in the comminution of food.18 As a consequence, CONCLUSIONS
mastication requires muscle activity to exert forces to cut
On the basis of the findings of this observational clinical
or grind the food,18 which may be reduced in the par-
study, the following conclusions were drawn:
ticipants with PD when compared with controls. Bakke
et al16 previously observed impaired masticatory perfor- 1. Oral rehabilitation with new removable dental
mance in patients with PD, but no difference in ME, prostheses improved OHRQoL and ME in elders
which they evaluated as the duration of masticating a with and without PD.
standardized apple slice.16 Because food characteristics 2. However, ME in elders with PD remained below
influence the number of mastication cycles needed to control levels.
prepare the food for swallowing,18 differences between
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