A RETROSPECTIVE REVIEW OF DENTAL IMPLANT SUPPORTED PROSTHESES

RESTORED IN A PROSTHODONTIC RESIDENCY PROGRAM IN THE UNITED

STATES OF AMERICA By

Kavitha P. Das, B.D.S., M.P.H., M.S.

Edited byJames M. Soberman, M.S., D.D.S., F.A.G.D, F.A.C.D

January 2011

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Contents

Abstract…………………………………………………………………………..

Introduction………………………………………………………………………

Background………………………………………………………………………

Purpose…………………………………………………………………………...

Materials and Methods……………………………….…………………………..

Results…………………………………………………………………………….

Discussion………………………………………………………………………..

Conclusion………………………………………………………………………..

Appendix………………………………………………………………………….

References………………………………………………………………………..

3

Acknowledgements

I would like to thank the faculty, staff and colleagues who assisted in the completion

of the project

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Abstract

Introduction

This report describes the outcomes of a retrospective chart review on dental

implant supported prostheses restored in the Department of Prosthodontics at

Columbia University College of Dental Medicine. The purpose of this review is to

evaluate the success rate of implants restored in a prosthodontic residency program

in a university setting, and assess post insertion visits and complications with

respect to the restored implants. Socio economic data, relevant medical and dental

information was collected and reviewed. For this retrospective study, the

prostheses were categorized as single implant crowns, implant supported fixed

partial dentures, complete fixed implant supported prostheses and complete

removable implant supported prostheses.

This report is phase I of a two phase study. Phase I includes a comprehensive chart

review.

Materials and Methods

All charts of patients treated in the Department of Prosthodontics from the year

2001 to 2006 were included in this study. A total of 101 charts were reviewed and

68 charts were narrowed down for the purpose of this study. Charts that did not

have information on the patient’s treatment plan were excluded from the 101 charts

reviewed.

5

Results

A total of three hundred and sixty implants were restored with an implant success

rate of 97.5%. More women were treated in the Department of Prosthodontics when

compared to men. The mean age of the patient was 61 years. The most frequently

restored dental implant was Biomet3I Osseotite, with implant single crowns

forming the largest group of prostheses restored. Hispanics and Whites formed the

most frequently treated groups of patients in this department, followed by Asians;

and self pay and Medicaid were the largest payment methods. Periodontal problems

followed by crowns on natural teeth were the most frequent dental history

recounted; hypertension followed by penicillin allergy were the most frequently

encountered medical complications; calcium supplements and multivitamins were

the medications listed most regularly; forty six percent stated that comprehensive

care and 30% stated the need for implant retained restoration as their chief

complaint. Panoramic radiographs were the most requested radiographs. The

average duration of treatment was 1.9 years and implant failure was the most

commonly seen implant related complication.

Limitations of the study

The major drawback of this study is the small sample size (68). A larger sample

would more accurately reveal the breakdown of various treatment options provided

to the patients.

6

Introduction

Osseointegrated dental implants have changed the approach to dental treatment.

The number of dental implants placed in the United States has increased, and it is

estimated that the field of implant dentistry will continue to grow by approximately

12% annually.1 The American Dental Association has reported the average survival

rates of multiple implant designs placed in various clinical situations as more than

90%.2 It has been estimated that more than 90% of surgical specialty dentists place

implants, 90% of prosthodontists restore implants, and 78% of general dentists

have used implants to support fixed and removable prosthesis compared to 65%

fifteen years ago. 3 The increased acceptance of dental implant treatment is

attributable to several factors, including patient’s expectations and acceptance,

endorsement by dentists and increased predictability of implant-supported

restorations.4,5

Background

In 1951, in Lund, Sweden, Dr. Branemark, an orthopedic surgeon discovered that it

was extremely difficult to recover bone-anchored titanium chambers that were

embedded in bone as a part of a vital microscopic animal and human study. The

titanium had seemingly bonded to living bone tissue. Dr. Branemark successfully

demonstrated that under carefully controlled conditions titanium could be

structurally integrated into living bone with a very high degree of predictability and,

7

without long-term soft tissue inflammation or ultimate fixture rejection. Dr.

Branemark named the phenomenon osseointegration. The first practical application

of osseointegration was the implantation of new titanium roots in an edentulous

patient in 1965. The discovery of use of titanium as the material of choice for

implantation was also a chance discovery. Dr. Emneus an orthopedic surgeon who

was studying various metals for hip-joint replacement introduced it to Dr.

Branemark. 6

More than forty years later, the field of dental implants has grown exponentially.7, 8

The vast majority of dental implants can be simply defined as a titanium screw that

is placed within the jawbone allowing a crown, fixed partial denture or complete

denture to be attached to it. Early implants used in the mid-twentieth century came

in a variety of shapes. These varied from implant frameworks that rested in direct

contact with the bone beneath the soft tissues, to blade shaped implants that were

placed within the alveolar bone. Most implants are commonly cylindrically shaped,

and are usually placed into a pre-prepared site within the maxillary or mandibular

bone.9

Purpose

Given the current trend in increased implant utilization by specialists and general

dentists, it is imperative that dental school curriculum in the United States includes

comprehensive training in implant dentistry. A few studies have been published on

the training provided in dental school settings. These studies have reported that the

implant survival of dental implants placed in a university setting is comparable to

8

implants placed by experienced clinicians 1,10 and that the implant success rate does

not vary depending on the implant system used. According to a study on pre

doctoral implant dentistry training in the United States published by Lim et al in

2008 11, 84 % of the schools reported that implant dentistry is part of the

curriculum, and 75% of the schools reported that the training provided was for an

average of 5.5 months.

Research has been carried out on the success or failure of different implant

supported prostheses, however, this has not been evaluated in university settings in

prosthodontic residency programs. Research needs to be carried out on implant

prostheses design and related factors in a prosthodontic residency setting.

The purpose of this report is to present the outcomes of phase I of a retrospective

study on dental implants restored in a prosthodontic residency in a university

setting in the United States. The first phase comprised of a chart review of patients

who had dental implants restored at the Department of Prosthodontics at Columbia

University College of Dental Medicine.

Materials and Methods

The study population consisted of patients treated at the Department of

Prosthodontics at Columbia University College of Dental Medicine from the year

2001 to 2006.

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Phase I:

A chart review:

The chart review included a comprehensive overview of the study subjects

background, medical history, dental history, insurance type and implant prostheses

related information. Information on nineteen variables was collected.

Patients registered in the Department of Prosthodontics were identified using

billing codes used to delineate various procedures for prosthetic treatment. From

this master list, charts retained in the chart room were identified and selected based

on their availability in the chart room. Nineteen variables were identified as

relevant to the study and the data was entered into an excel spreadsheet.

Appendix 1 - list of variables collected from the chart review.

Phase II:

Clinical and radiographic evaluation of the implant supported prostheses:

The clinical evaluator measuring clinical parameters will fill out a questionnaire and

will assess different clinical parameters on prostheses and implant supported

prostheses success/failure will complete the questionnaire. This questionnaire will

address specific clinical variables related to the prosthesis and will include

radiographic evaluation of the prostheses as well as complications associated with

the prostheses.

Appendix 2 -lists details on the clinical variables to be included in the study.

10

A self-administered questionnaire on OHRQOL to be filled out by the study subject:

The use of a validated instrument strengthens a study .The OHRQOL will be

measured using the validated instrument, the Oral Health Impact Profile (OHIP).

The OHIP was developed with the aim of providing a comprehensive measure of

self-reported dysfunction, discomfort and disability attributed to oral conditions.

These impacts were intended to complement traditional oral indicators of clinical

disease. 12 The questionnaire will also collect data on each study member’s

occupation, education, income and related socio-demographic information. This

questionnaire will be administered to the patient.

Appendix 3- OHIP-14.

This report will enumerate the results of phase I- the chart review.

Results

A total of 101 charts were reviewed and 68 charts were narrowed down for the

purpose of this study. Charts that did not include treatment plan details were

excluded from the study.

Socio Demographic Variables:

Sex: The results of this study revealed that more women were treated in the

Department of Prosthodontics. Sixty two percent were women and 38% were men.

11

Sex distribution

Race: Information with respect to race was not available in all charts. Based on

availability, it was found that Hispanics and Whites comprised most of the treated

patients, followed by Asians and African Americans.

Race distribution

12

Age distribution:

Age distribution

Most of the patients treated were between the age group of 62 to 69 years.

Interestingly, the third largest age group was above the age of 80. The patient’s age

was between 22 and 87 years with a mean age of 61. The mode was 67 years.

Health Insurance Type: Most of the patients paid out of pocket for their treatment,

followed by Medicaid. Medicare, MetLife, NYS Empire Plan and Careington Care

followed this.

13

Insurance type

History:

Medical History:

The most frequently occurring medical disorder was hypertension, followed by

penicillin allergy. Most patients said that they had no significant medical history

(n=24). Interestingly, only 3 of the 68 charts reviewed had data on smoking history.

None of the patients claimed to be current smokers. One patient was listed as

current pipe smoker.

14

Medical History

Dental History:

Periodontal problems, crowns, root canal treated teeth, restorations (both

composite and amalgam) and dental implants were most commonly cited as past

dental treatment procedures. Partial edentulism was the second highest past dental

treatment, preceded by periodontal problems. Only 5% of the patients reported

having a history of decay whereas 15% of the patients reported having periodontal

problems.

15

Dental history

Chief Complaint:

Majority of the patients stated that comprehensive care was their chief reason for

wanting dental treatment (46%) and the second highest chief complaint was the

patient’s perceived need for an implant-retained restoration (30%). Only 7%

reported aesthetics as a chief complaint. Nine percent wanted crowns on natural

teeth.

Chief complaint

16

Medications:

Calcium supplements and multivitamins were the most commonly listed

medications followed by Synthyroid and Hydrochlorothiazide.

Medications

Radiographs:

Panoramic radiographs, periapical radiographs and full mouth series were

frequently requested. Only 6% of the patients had a CT scan taken.

17

Radiographs requested

Treatment plan for implant supported prostheses:

Treatment Plan

For the purpose of this study, implant supported prostheses were divided into four

categories:

1. Implant single crown

2. Implant fixed partial denture

18

3. Completely edentulous removable prostheses

4. Completely edentulous fixed prostheses

A vast majority of the restorations provided in the clinic were implant single crowns

(88%). This was followed by implant fixed partial dentures and completely fixed

partial dentures (9%). Removable full arch implant supported prostheses

comprised less than 3% of the restorations.

Implant systems:

Three hundred and sixty implants were restored. The most frequently used implant

system was the Biomet3I Osseotite followed by Branemark system MkIII and

Biomet3I Osseotite Certain.

Frequency of Implant Systems Utilized

Ninety-six Biomet3I Osseotite external connection implants were placed. This was

followed by Branemark system MkIII and Biomet Certain internal connection. Sixty-

eight Replace Select (internal connection) implants were placed and restored.

19

Type of Implant Number

Straumann6

Biomet3I Certain 82

Biomet3I Osseotite 96

Branemark MkII 9

Brannemark MkIII 90

Branemark MkIV9

Nobel Biocare Replace Select 68

Implant length: The most frequently restored implant length was 11.5mm followed

by 13mm and 10mm. The shortest implants placed were 8.5mm.

Implant length

20

Duration of treatment:

Total time taken from start of prostheses to delivery. The y–axis represents the number of patients.

Time taken from start of prostheses to delivery was computed for all the patients.

Twenty one percent of the total prostheses were delivered in 400 to 500 days, 13%

in fewer than 100 days and 9% in 200 to 300 days. For the purpose of this study the

prostheses start date was the date that the final impression was taken. On an

average it took one year and nine months to complete the prostheses.

21

Complications:

The most frequently occurring complication was implant failure, which amounted to

41% of all complications. Exposed implant threads was the second complication at

36%, followed by food impaction or problems due to proximal contacts.

Follow up visits:

One follow up visit post insertion was the most common, followed by two visits.

Follow up visits

Data on follow up visits were not available. The vast majority of patients did not

return for follow up visits. Follow up visits were more likely to be documented in

cases that had complications.

22

Discussion

This report enumerates the results of a retrospective chart review on existing

patient charts available in the College of Dental Medicine at Columbia University,

New York. The Phase I of this study focused on gathering data on the patient’s

background, history, chief complaint, type of prostheses, implant type and duration

of treatment.

Awareness of dental implant treatment modalities has increased, and thus implant

treatments are more commonly accepted .For the majority of the population, the

clinical success of dental implant therapy has improved such that it has been

recognized as standard of care for certain prostheses types.13 Due to advancement

of technology and the current ease of accessibility to information, the general public

is able to research, visualize, and understand the advantages of dental implant

treatment. Improved chewing force and overall improved functionality of implant-

supported prostheses had been reported by Berg,14 Carlson et al15 and Lindquist.16

Ease of accessibility to information, more effective techniques and methodologies

that reflect a higher success rate is also the reason for increased acceptance of

dental implant supported prostheses. However, careful patient selection is needed

to ensure successful outcome. The patient needs to have an accurate assessment of

the procedures, the length of treatment time, risks and alternatives to implant

treatment. The trends in various new designs and methods are fast paced and

patients need to be informed of various options available to them.

23

Prostheses type: It must be noted that majority of the implants restored in the

Department of Prosthodontics were single crown implants. This chart review also

revealed that 88 porcelain fused to metal crowns were placed in the same

population. This is a lot less than the total number of implant supported single

crowns, which comprised 88% of all the implant, supported prostheses restored.

Lindh and Gunne, found in their meta analysis that implant survival was slightly

better for single crowns when compared with fixed implant supported prostheses.17

However, Weber and Sukotjo did not find higher success with implant single crowns

when compared to fixed splinted prostheses in a study published in 2007.18

Implant success: A total of three hundred and sixty implants were restored with an

implant success rate of 97.5%. According to Carl Misch, the term early implant

success is suggested for a span of 1 to 3 years, intermediate implant success for 3 to

7 years, and long-term success for more than 7 years. The implant success rate

should also include the associated prosthetic success or survival rate. Since this

study reviewed charts from 2001 to 2005, success can be categorized as

intermediate success of the implant.19 Information on the prostheses type will be

collected in the second phase of the study to determine the success and survival rate

of an implant supported prostheses. The type of abutment, the form of retention

(cement or screw retained) and the type of restorative material used will also be

evaluated for determining overall prosthetic success.

24

Implant type: The results on implant success rate obtained in this study are

comparable with data published on implant success in experienced clinicians and

residents in other surgical and general residency programs. In a retrospective study

published in 2004, on implant success in a general dentistry residency program,

authors Mohamed Maksoud and Clifford Starr state that the implant success rate

was 98.2% after a follow up of 6 months to 4 years.Error! Bookmark not defined. The study

population was 57% women and 43% men. The implant system evaluated in this

study were SteriOss (NobelBiocare, Branemark Novum ,Taperer-Lock (Zimmer

Dental), and ITI (Straumann). The success rate of implants placed in private practice

has been documented. In a study, which analyzed the success of 1003, implants

placed in 376 patients, the authors Lemmerman et al, state that the success rate was

approximately 95%. 20 Bahat demonstrated similar implant success rate in private

practice in another study where 660 Branemark implants were followed for 5 to 12

years.21 The success rate in the Bahat study was 93.4%. In the current retrospective

chart review, 62% were women and 38% were men. The implant systems restored

here were Straumann, Biomet 3I Certain, Biomet3I Osseotite, Branemark MkII,

Branemark MkIII and Branemark MkIV.

Implant length: The most frequently used length for dental implants restored in the

department were 11.5mm followed by 13mm and 10mm. This in accordance with

literature published by Jemt and Lekholm, 22 Naert et al; 23 Weng et al and

Herrmann et al, 24 which has favored the placement of longer implants to increase

25

implant survival rate. Babbush and Shimura study also demonstrated that longer

dental implants had a higher success rate.25 However, various authors have

reported good survival rates with shorter implants. Van Steenberghe et al, 26 Friberg

et al, 27 Jemt, 28 and Lekholm et al 29 have demonstrated that adequate survival of

implants can be obtained with the use of short implants. Some authors believe that

the use of implants over 12mm have higher chance of failure due to operator factors

such as longer drilling time, lesser ability of coolant to penetrate the osteotomy, or

inadvertent, increased drilling force to get a deeper osteotomy. xvii Buser et al, 30

Ellegaard et al, 31 Stellingsma et al 32 and Feldman et al, 33 reported that implant

length did not appear to significantly influence the implant survival rate . In this

retrospective chart review, 33% of the implants were 13mm long and 37% were

10mm long. The shortest implant restored in the Department of Prosthodontics was

8.5mm long. This accounted for 3% of all the implants restored. Seventy of the 360-

implant sites had bone augmentation.

Implant abutment interface: According to a literature review published in 2008,

author Theoharidou states that most invitro studies except one, have demonstrated

that internal connection implants are more mechanically stable than external

connection when restoring single implant crowns.34 Peirmatti et al, in their invitro

study have shown that external connection has better mechanical stability than

internal connection. Some authors prefer the use of internal connection implants for

sites where higher torque values are needed.35 However, research conducted in the

US market reveals that external connection implants are still more frequently used

26

than internal connection implants despite an increase in the sales of internal

connection implants in recent years. 35 Data collected from this retrospective study

shows that both internal and external connection implants were restored. Fifty

seven percent of the implants were external connection and 43% were internal

connection implants.

Radiographs: The most frequently requested radiographs were the panoramic

radiograph (32%) followed by full mouth series radiographs (31%) and periapical

radiographs (30%). Only 6 percent of the patients had CT scans requested. One

patient had a CT scan requested for Nobel guide surgery.

Complications: Implant failure requiring removal of the fixture was the most

frequently seen complication and amounted for 41% of all complication. Among the

failed implants, 33% of the failed implant sites had bone augmentation (Bioss).

Implant failure was seen more frequently in men (7) than in women (2). One

patient with implant failure was a pipe smoker. Thread exposure of more than two

to three threads due to bone resorption was the second most frequently seen

complication (36%). The other complications reported were stripping of the screw,

food impaction and incorrect placement of the implant.

Duration of treatment: For the purpose of this study the prostheses start date was

the date that the final impression was taken. On an average it took one year and 9

months to complete the prostheses. There is a paucity of literature available on the

27

average time taken to deliver prostheses in a Prosthodontic residency setting, so

comparison with another program is not possible. Factors that could account for

the length of procedure could be:

1) Treatment provided by residents in a residency program

2) Treatment is provided in a university setting requiring authorization of

procedures, and

3) Lack or delayed availability of prosthetic implant parts and materials

Health Insurance: The dental school at Columbia University accepts Medicaid and

self-payment for treatments rendered, which is reflected in the insurance plan

distribution among the patients. Forty four percent of the patients were self-pay

and Medicaid covered 31%. Despite the coverage extended for conversion of

complete dentures to implant supported removable prostheses, the percentage of

overdentures (2%) was lower than the percentage of fixed full arch prostheses

delivered (3%).

Age: It is estimated that New York City will see substantial increases in its elderly

population. The number of persons ages 65 and over is projected to rise 44.2

percent, from 938,000 in 2000 to 1.35 million in 2030. The average age of the

patient treated in the Prosthodontic department reflects this trend. The highest age

group treated in the department was between the ages of 60 to 70 years and the

third highest group was above the age of 80 years. To achieve predictable esthetic

and functional outcomes of implant treatment for geriatric patients, comprehensive

28

diagnosis and treatment planning is required. The patient’s medical and dental

history for bruxism, periodontal disease, tobacco use, uncontrolled diabetes mellitus

and metabolic diseases of bone need to be assessed and evaluated before implants

treatment.36

Medical History: In this study, the patient’s medical history listed hypertension,

arthritis and diabetes type 2 as some of the most common medical disorders.

Fiorellini et al and Klokkevold have stated that patients with Type 2 Diabetes are at

higher risk for failure of implants,37 particularly older patients.

Smoking history: This chart review also revealed that smoking habits of patients in

both adult and geriatric patient was not routinely documented. According to a

dental literature review conducted by Perry Klokkevold in 2007 using Medline,

Cochrane Collaboration and Embase databases, the author concluded that smoking

adversely affects the outcome of implant survival and success rate.38 Sanchez-Perz et

al and PK Moy et al, have reported elevated complications related to smoking after

controlling for age and other medical conditions;39,40 it is thus, important to assess

smoking history in the elderly.

The data from this study revealed no current cigarette smokers and one pipe

smoker.

Race: The breakdown of various groups according to race in the retrospective study

is in accordance with data on the race distribution in New York City. According to

29

projections from the U.S. Census Bureau, the New York City has the largest Asian

(Chinese) population of any city outside of Asia and the largest Puerto Rican

population anywhere in the world. The largest Dominican population outside of

Santo Domingo resides in New York City. 41 Forty three percent of the city’s

population is White. The largest groups of people treated in the department belong

to the Hispanic (31%), White (31%) or Asian (25%) background. African Americans

comprised 13% of this population. Although variations in implant success in

different ethnicities has not been observed, there are very few studies reporting on

race and implant success. One study, a retrospective multicenter cohort study on

two stage implants published in 2006, carried out in the South Korean population

states that there is no significant difference in implant success rate in the Korean

population and other published data on implant success.42

Utilization of health services: Utilization of health services varies by gender and age.

Some studies report that females are more likely to seek care than males.43, 44

However, other studies state that there is no variation in health seeking behavior in

males and females.45 Some published studies have stated that older men are more

likely to seek care. 46Mustard et al, state that expenditure for health is the same for

men and women. 47 The data gathered from this chart review shows that women are

more likely to seek dental treatment than men. The average age for women was 59

years and the average age for men was 65 years.

Missing data and lack of documentation: A large number of charts reviewed had

missing data or did not systematically document dental services rendered. Data on

30

socio economic variables, smoking behavior and race were not consistently

documented. However, data on implant type was included in all the 68 charts

reviewed. This could be due to the use of stickers provided by the manufacturer.

Using standardized forms to document prosthetic and surgical procedures might aid

the documentation process.

Conclusions

A hundred and one charts were reviewed and 68 charts were included in this study.

The following are the outcomes of the chart review:

1. The implant success rate is comparable to the general population and other

general and surgical residency programs.

2. Implant single crowns were the most frequently restored prostheses.

3. External connection implants with length 10mm and above were the most

frequently utilized implant.

4. Branemark implant system was the most frequently used implant.

5. The average time for completion of a prostheses was 1 year and nine months.

The results of this study will be strengthened by increasing the sample size and by

evaluating the implant-supported prostheses by clinical and radiographic

examinations.

31

Appendix 1CHART REVIEW SHEET

SES INFORMATIONSex DobRaceMedical historyMedicationsInsurance typeChief complaintDental historyRadiographsTreatment plan

IMPLANTS RELATED INFORMATIONDate implants placedType of implants placedBone augmentationOther relavent information wrt implantsComplications

PROSTHESESStart date of prosthetic treatmentDate deliveredNumber of post insertion visitsComplications associated with the prosthesesOther

32

Appendix 2Clinical Evaluation Questionnaire

Study number:

1) Is prosthesis mobility present? Yes No

2) Is there mobility of implants? Yes No

3) Is there any sign of localized infection around the implants or implant prosthesis?

a. Gingival irritation: Severe Moderate Minor

b. Suppuration present: Yes No

4) Is bone loss noted around the implants? Greater than 50% - Yes No

5) Oral hygiene status around implant prosthesis- Good Fair Poor

6) Is the patient satisfied with prosthesis mastication? Very satisfied Generally satisfied Dissatisfied

7) Is patient satisfied with esthetic outcome? Very satisfied Generally satisfied Dissatisfied

8) Is patient satisfied with phonetic outcome? Very satisfied Generally satisfied Dissatisfied

9) Were you satisfied with the time limit of treatment? Yes No

10)Are there any soft tissue complications around implants or prosthesis? Yes No

11)List prosthetic complications associated with the prostheses

33

Appendix 3Oral Health Impact Profile Questionnaire

Study number:Sex:Age:Occupation:Race:Insurance type:Education:Income:

Functional Limitations1. Have you had trouble pronouncing any words because of problems with your teeth, mouth, or dentures? (0.51)

2. Have you felt that your sense of taste has worsened because of problems with your teeth, mouth, or dentures? (0.49)

Physical Pain3. Have you had painful aching in your mouth? (0.34)

4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth, or dentures? (0.66)

Psychological Discomfort5. Have you been self conscious because of your teeth, mouth, or dentures? (0.45)

6. Have you felt tense because of problems with your teeth, mouth, or dentures? (0.55)

Physical Disability7. Has your diet been unsatisfactory because of problems with your teeth, mouth, or dentures? (0.52)

34

8. Have you had to interrupt meals because of problems with your teeth, mouth, or dentures? (0.48)

Psychological Disability9. Have you found it difficult to relax because of problems with your teeth, mouth, or dentures? (0.60)

10. Have you been a bit embarrassed because of problems with your teeth, mouth, or dentures? (0.40)

Social Disability11. Have you been a bit irritable with other people because of problems with your teeth, mouth, or dentures? (0.62)

12. Have you had difficulty doing your usual jobs because of problems with your teeth, mouth, or dentures? (0.38)

Handicap13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth, or dentures? (0.59)

14. Have you been totally unable to function because of problems with your teeth, mouth, or dentures? (0.41)

35

References

36

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4 Muller F, Wahl G, Fuhr K: Age-related satisfaction with complete dentures, desire for improvement and attitude to implant treatment. Gerodontology 11:7, 1994

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