Prosthetic rehabilitation with removable dentures positively influences quality of life in older patients: a systematic review

A reabilitação protética com próteses removíveis influencia positivamente a qualidade de vida de pacientes idosos: uma revisão sistemática

Jandenilson Alves Brígido

Centro Universitário Fametro (Unifametro), Brazil

Wellington Luiz de Oliveira da Rosa

Universidade Federal de Pelotas, Brazil

Rafael Guerra Lund rafael.lund@gmail.com

Universidade Federal de Pelotas, Brazil

Tooth loss leads to functional limitations and has a psychological impact, significantly affecting self-esteem.1 Global population aging and extraction-based dental practice in former decades have resulted in many edentulous people.2 Since edentulism damages oral health-related quality of life (OHRQoL),3 oral rehabilitation is needed to restore masticatory and speech function and esthetic appearance.4

A study evaluating responses from the 2010 National Oral Health Survey5 found prevalences of 78.2% and 68.7% for the use of and need for dental prosthesis, respectively, among older Brazilians (65-74 years). Tooth loss damages OHRQoL,6 leading to chewing problems, dietary restrictions, speech difficulties, loss of facial support, decreased occlusal vertical dimension, and esthetic impairment.7 However, it remains unclear whether oral prosthetics can alleviate these effects and which type of dental prosthesis yields the greatest improvement in quality of life.

Various treatments have been proposed to replace lost teeth and restore function and esthetics in partially or completely edentulous patients.6 Conventional complete dentures supported by the mucosa are the traditional and most common method of oral prosthetic rehabilitation for edentulous patients. Other options include removable or fixed partial prostheses and osseointegrated implants with overdentures.8 Patients seek solutions to compensate for tooth loss and regain their self-esteem. Thus, enhancing quality of life is a primary treatment goal of prosthetic oral rehabilitation, and patient satisfaction is relevant to treatment quality and the success of the most appropriate therapy in each clinical situation.9

OHRQoL is a comprehensive patient-centered measurement system for assessing the impact of oral problems and pathologies on individual well-being. Evaluating patient satisfaction with professional dental interventions is essential.6 The Oral Health Impact Profile (OHIP), a popular tool for OHRQoL analysis, consists of from 12 to 53 subjective questions. These multidimensional questionnaires are quick to administer and score, allowing assessment of the severity, extent, and prevalence of negative impacts through a single application or application at different time points.10 The OHIP has been translated into many languages, and its validity and internal consistency have been confirmed in a number of countries.11 The Geriatric Oral Health Assessment Index is another frequently used OHRQoL scale among older patients.12

Evaluating the effectiveness of oral rehabilitation for tooth loss is crucial to improving its intended masticatory, speech, and esthetic effects.1 Previous systematic reviews have investigated differences in OHRQoL and patient satisfaction with dental prosthetics.13,14,15 However, the influence of prosthesis type (complete dentures, implant overdentures, and removable partial dentures) on the quality of life of older patients remains unclear. Thus, this systematic review assessed the effects of prosthetic rehabilitation with removable dentures on the OHRQoL of older patients.

Only 75 of the 738 initial search results were selected for full-text analysis, of which 67 were excluded: 36 were not RCTs or prospective studies, 29 did not involve a population of older adults, and 2 were study proposals. Three additional articles were included from the manual reference search, resulting in 11 studies for the systematic review. The study selection flowchart is presented in Figure 1.

FIGURE 1.
PRISMA study selection flowchart.

The studies were conducted between 2003 and 2020. All patients underwent prosthetic rehabilitation and responded to a questionnaire assessing post-treatment OHRQoL. Table 112,21,22,23,24,25,26,27,28,29,30 presents the characteristics of the included studies. The sample size ranged from 25 to 102 patients, and the mean patient age ranged from 62 to 74.2 years. Only 1 study included > 100 participants.26 Each article underwent a thorough assessment, and relevant data were extracted and tabulated. Four articles were RCTs,23,24,29,30 and the remaining 7 were prospective clinical studies.12,21,22,25,26,27,28 Due to substantial variations in methodology, study design, and outcome, a meta-analysis was impossible.

TABLE 1.
Detailed data from the included studies.

TABLE 1.
Detailed data from the included studies.

OHRQoL: Oral Health-Related Quality of Life; CD: Complete Dentures; OHIP-EDENT: OHIP for Edentulous Patients; RPD: Removable Partial Dentures; SDA: Shortened Dental Arch; OHIP: Oral Health Impact Profile; RCT: Randomized controlled trials; IOD: Implant Overdenture; GOHAI: Geriatric Oral Health Assessment Index; SF-36: Short Form Health Survey

Two of the studies compared fixed restoration groups (based on the shortened dental arch concept) to removable restoration groups,23,24 and 3 compared complete denture groups to overdenture groups.26,29,30 One study evaluated OHRQoL in patients rehabilitated with implant-retained mandibular overdentures,25 while the others examined the impact of oral health-related conditions on patient quality of life before and after prosthetic treatment with complete dentures.12,21,22,27,28 Nine studies used a version of the OHIP questionnaire to assess the effects of oral conditions on quality of life. The post-treatment follow-up period ranged from 4 weeks to 2 years.

Dental prostheses usually improved most OHRQoL domains,12,21,22,23,24,25,26,27,28,29,30 mainly functional limitations, physical disabilities, and psychological aspects. Implant overdentures were more likely to improve OHRQoL than complete dentures.26,29,30 Fixed adhesive prostheses were associated with significantly higher mean OHRQoL scores than removable partial dentures.23,24 Mandibular two-implant overdentures effectively improved OHRQoL in edentulous patients.

The risk of bias between and within studies is presented in Figures 2A and 2B (RCTs) and Figures 2C and 2D (prospective clinical studies). There was a high risk of bias in 1 of the 4 RCTs. There was no risk of bias in any domain in 2 of the prospective clinical studies.

FIGURE 2.
A, risk of bias graph. B, risk of bias summary for randomized controlled trials (RCTs) based on the revised Cochrane risk of bias tool for RCTs (RoB 2). C, risk of bias graph. D, risk of bias summary for prospective clinical studies based on the ROBINS-I tool.

This systematic review focused on the effects of prosthetic rehabilitation on OHRQoL in older patients. Removable dentures were associated with improvements across various OHRQoL domains. Several clinical studies assessed patient satisfaction with speech, masticatory function and efficiency, and the need for follow-up appointments for different dental prosthesis types, including complete dentures, removable or fixed partial prostheses, and implant overdentures.12,21,22,23,24,25,26,27,28,29,30

Studies analyzing OHRQoL in patients undergoing prosthetic oral rehabilitation with complete dentures showed improvements in most domains, especially functional limitations, physical disabilities, and psychological aspects.12,21,22,27,28 There was significant improvement in chewing, social interaction, satisfaction with appearance, and worry/embarrassment. Sex differences were found, with women usually experiencing better outcomes, possibly due to a greater acceptance of prosthetic treatment.12 However, the least affected domains were physical pain and social disability, which was likely due to the challenges of adapting to complete dentures.

Three studies compared OHRQoL between implant overdentures and complete dentures.16,29,30 Implant overden-tures significantly increased OHRQoL in these studies, including psychological and social domain improvement. This might be due to enhanced masticatory efficiency with implant-retained prostheses.26,29,30 Cross-sectional studies and systematic reviews involving adult patients have reported similar findings, highlighting drastic improvements in retention, stability, comfort, speech, and masticatory efficiency with overdentures, thus increasing patient satisfaction and OHRQoL.11,13

Two studies compared functional treatment with fixed adhesive prostheses to removable partial dentures in partially edentulous older adults.23,24 Functional treatment with fixed prostheses resulted in significantly higher OHRQoL scores than removable partial dentures. This might be attributed to the similarity of fixed dentures to natural teeth, since patients do not need to remove the prosthesis, thereby simulating a more realistic experience of natural teeth. However, a recent study reported different findings, ie, that both restoration types improved OHRQoL, but removable dental prostheses resulted in greater improvements than fixed restorations in various dimensions.10

Older people frequently report tooth loss, and dental prostheses can improve esthetics, speech, psychological aspects, and masticatory efficiency. Such improvements affect dietary intake and nutritional status, improve social acceptance, and directly influence quality of life.23,27

Nine of the 11 studies used versions of the OHIP questionnaire, which provides information on self-perceived oral health. Due to being more time-consuming, the OHIP-49/53 was used in only 1 study. Three studies used the OHIP-20, 2 used the OHIP-14, and 3 used the OHIP-EDENT, a specialized version for edentulous patients. Two studies used the Geriatric Oral Health Assessment Index to assess quality of life and treatment satisfaction.

Many patients show little interest in implant treatment despite the proven benefits of implant-retained overdentures, such as residual alveolar bone preservation, improved masticatory efficiency, and increased overdenture retention and stability. This reluctance may be due to the fear of surgical interventions and/or their associated costs.

Most of the included studies were conducted at specialized dental prosthesis clinics. It would be beneficial to investigate the outcomes in primary care settings, where most of the general population is treated.8 Additionally, using different instruments to assess OHRQoL, such as other OHIP versions, makes it difficult to compare studies. Cultural and international differences may also influence various aspects of OHRQoL with respect to dental prostheses.26

The limitations of the included studies were the relatively short follow-up periods and small sample sizes. Longer follow-up is necessary to assess the long-term impact of different prostheses on OHRQoL. The data should be interpreted with caution due to the small sample sizes. These findings should serve as a basis for further studies in the field.

The evidence from the included studies indicates that prosthetic rehabilitation with removable dentures positively affects OHRQoL in older patients. However, patients with complete dentures experience lower OHRQoL than those with overdentures. Moreover, functional treatment with fixed adhesive prostheses yielded significantly higher mean OHRQoL scores than removable partial denture treatments. These findings underscore the relevance of dental prosthesis type for OHRQoL in older patients.