Age-related satisfaction with completedentures, desire for improvement andattitudes to implant treatment

Frauke Muller, Gerhard Wahl* and Klaus FuhrUniversity of Mainz, Department of Prosthetic Dentistry; *University of Bonn, Department of OralSurgery, Germany

In the edentulous lower jaw implant stabilised dentures have proved clinically so successfulthat the indication for this treatment is now being discussed more often with geriatric patients.The aim of this study of edentate subjects was to determine the age-relation of the demandfor denture improvement, the risks and feasibility of implant treatment. Sixty four completedenture wearers aged from 42 to 84 years took part in the study. A questionnaire was used todetermine the subjective demand for denture improvement. For 33 subjects implants seemedpossible. For these patients fear and scepticism concerning implant treatment were specifiedand quantified. Impaired general health was the most frequent absolute contra-indication forimplants; the local oral prerequisites tended to be slightly less favourable in elderly. Olderpatients were more satisfied with poorly fitting dentures and were less prepared to take trou-ble to achieve denture improvement. Although scepticism concerning implant treatment wasnot age-related, patients who were keen for an improvement of their dentures were signifi-cantly younger and less sceptical about implants.

Key words: complete denture satisfaction, ageing, implant contra-indication

Gerodontology 1994; 11(1): 7-12

Introduction

With increasing clinical experience in implantology,edentulous patients are more often informed aboutthe possibility to improve their denture retentionthrough the insertion of osseointegrated implants'-.The consequent improvements in masticatory abilityand comfort not only support oral rehabilitation butalso enhance social self confidence further increas-ing "quality of life"^^ In younger edentulous patientsfavourably shaped alveolar ridges, good muscularcoordination and adaptive capabilities contribute tosubjective satisfaction with the dentures. This isespecially the case when the loss of teeth and theirprosthetic replacement run over a long period oftime, so that the impairment in function progressesinsidiously and is therefore unnoticed to the patient.Unlike the first partial dentures, these completeprostheses are less likely to be thought of as"crutches" which only partially restore the self

confidence^ The latter is more hkely the case whena young patient is confronted with edentulism withina short period of time or the lackof alveolar ridge andother problems of oral conditions contribute toserious functional deterioration^ For these patientsthe stabilisation of dentures with osseointegratedimplants greatly enhances rehabilitation*^. In contrastelderly patients more often tend to tolerate function-ally poor dentures'. The suggestion of stabilising thedentures with implants, or even the mere replacementof the existing conventional dentures, is oftendeclined with a reference to their age. The aim of thisstudy was therefore to assess the age-relation of thedemand for denture improvement in edentatesubjects in relation to clinical findings and denturesatisfaction. Furthermore, we tried to determineprofessionally perceived risk and feasibilities ofimplant treatment and to evaluate the subject's fearand scepticism towards implants.

©The Gerodontology Association 1994Volume 11, No.l

H Mullci. WahlaiKll-uhr

4 0 - 1 4 4 5 - 4 4 .SO-5-1 55-5"> Ml M hS M 71174 75 7') i V.U

Figure I Age and gender distribution of subjects

Material and Methods

Sixty four complete denture wearers, 33 women and31 men, participated in the study. Two furtheredentate subjects were excluded because of previousimplant failure. The subjects' age ranged from 42 to84 with an average of 69.5 (±9.4) years (Figure I).All subjects were patients at the dental schools ofBonn or Mainz and had received either replacementdentures or requested treatment such as repairs orrelining at least 2 weeks prior to the investigation.None of the patients attended to seek treatmentalthough some combined the visit with counsellingfor possible denture improvement.

Medical history and clinical examination

A clinical examination was performed which empha-sised the following aspects:• clinical functional analysis of the orofacial system;• assessment of denture retention (good - average

- poor);• vertical dimension and appearance of dentures;• alveolar ridge resorption according to Atwood*';• the health condition of oral tissues;• oral hygiene; and• radiographic fmdings (OPG).

Based on this, patients were allocated with regardto risk criteria and feasibility of implant treatmentinto the categories "normal risk", "feasible", "withrisk" and "not possible". Likewise the general healthwas assessed for systemic risks.

Denture satisfaction

The subject's satisfaction with the present dentureswas evaluated using a questionnaire. TTie subject wasread 10 statements and asked to agree or disagree ona scale from "applies completely", "does apply", "Idon't know", "does not apply*' to "does not apply atall". Accordingly the score ranged from 0 to 4 for

each answer. The statements were in order:• I can chew well with my dentures.• Since I have been wearing dentures, I dislike

answering the phone.• Mike the appearance of my dentures.• My dentures are tight and firm.• I avoid going out for meals because I have

difficulties in chewing.• I can speak well with my dentures.• When alone, I often remove rny dentures.• My face looks altered by my dentures.• 1 aiii so used to my dentures that 1 rarely think

about them.• My dentures move during speech or careless

movements.

From these data a "Denture Satisfaction Index"(DSI) was calculated ranging from 0 for no satisfac-tion to 40 for complete satisfaction.

Impro vem ent-de mand

The subjective demand for an improvement of thedentures was rated on the scale "unconditionallyyes', "yes, if easy", "indecisive", "no, not necessary"and "no, not at all".

Fear and scepticism about implants

All subjects, except those who suffered from severedementia, were read an information sheet concerningthe principles of implant treatment in order toprovide the knowledge necessary to answer thefollowing questions. All subjects were asked whetherthey would consider implant treatment and if not, tospecify their reasons. Only those subjects who wereconsidered suitable for implants from their medicalhistory and oral findings (n=33) were presented aquestionnaire to specify and quantify their fear andscepticism about various aspects of the implant treat-ment. The questionnaire covered the topics:

- implant rejection,- operation to insert implants,- injections for anaesthesia,- X-rays for diagnosis and control.- the concept of an implanted "foreign body",- extensive oral hygiene,- the costs of the treatment,- the overall time required for the treatment,- confidence in clinical experience with

implant treatment,- fear of possible disappointment about the

outcome.

The fear of or objection to each issue was assessedon a scale from 0 to 4 and analysed both, separately

Gerodontology

Denture satisfaction and improvement demand 9

411

(DSI)3H

Figure 2. Contra-iiulications for impluntation a riskassessment

and as a cumulative "Implantation Index" (II), rang-ing from 0 for maximum level of concern to 40representing none.

Statistical analysis

Unpaired two-tailed t-tests were employed for allgroup comparisons. For scattergrams the Pearsoncorrelation coefficient "r" as well as the likelihoodfor the linear regression being different from zerowere applied.

Results

Contra-indications for implantation - a riskassessment

The data showed clearly that poor general health ismore frequently considered an absolute contra-indication than the local factors (Figure 2).

Table 1. Diseases which were considered asabsolute contra-indication for implants. Somepatients had several diseases

Disease (n)

Dementia 7Diabetes mellitus (insulin dependent) 6Cardiac infarction 6Haemorrhagic syndromes 6Psychosis 3Cerebral stroke 2Epilepsy 2Extreme dyskJnesia 2Hepatic cirrhosis 2High blood pressure 1Pulmonary emphysema 1Leucocytosis 1Cortisone-medication effects 1Radiation effects 1Alcoholism 1Cardiovalvular transplant 1

M)

25-

2(1 -

15-

10

40 60 fc5

o good (n = 21; n.s.)A average (n = 19; n.s.)• poor (n = 24; r = 0.63; p< 0.0011

Figure 3. Age relation of denture satisfaction (DS!). Groups of'good', 'average' and 'poor' denture retention weredistinguished clinically

The medical history was considered an absolutecontra- indication in 25 subjects, with an average ageof 72.2 (±7.6), in 9 cases, aged 72.0 (±6.9), thesewere the local oral findings whereas in 3 subjects animplantation was contraindicated for both reasons.Table 1 lists the frequency of diseases which ac-counted for contraindication to implants. Sevensubjects with an average age of 77.9 (±5.1) sufferedfrom dementia. Besides the latter, diabetes mellitus,cardiac infarction as well as haemorrhagic syn-dromes were the most frequent diseases. Except fordementia, no relationship between absolute contra-indication due to medical history and age could bedetermined. It also should be noted, that there was asubtle non- significant trend in the oral findings todeteriorate with age.

Denture satisfaction and improvement-demand

The subject's satisfaction with the dentures showedno significant age-relationship. However, after datawere split into groups with "good", "average" and"poor" denture retention, there was a significantcorrelation of r=0.63, (p<O.OOl, n=24) between the

Do you want an improvement of your denture?

unconditionally yes

yes. if easy

indecisive

no, not necessary'

no. not at all

piO.0002

piOOOOS

20 30

Figure 4. Relation of improvement-demand to the denturesatisfaction (DSI) (n=64)

Volume I 1, No. I

10 Miillcr. Wahl and Fuhr

lVi>ow "i>iil an improvcmcnlol >our dcnturo?

yes. if easy

1, not at .-ill

'7.:---/y7/-'/y//:'/y,:y/-y///A'/M<ry//MfeM -^

0 10 20 30 40 SO 60 70 BO 90

Figure 5. Age relation of demand for denture improvement

DSI and the age of patients with "poor" retention ofthe lower denture (Figure 3).

As expected the satisfaction with dentures (DSI)also resulted in a lower demand for denture improve-ment (p<O.{X)OS) (Figure 4). The DSI of those 16subjects who wanted an improvement of theirdentures in any case and therefore answered "uncon-ditionally yes" was significantly lower than in those16 patients who wanted an improvement, hut werenot prepared to take trouble such as time or expenses("yes. if easy"). Two patients were indecisive. 14 didnot consider improvement was necessary and 16 didnot desire improvement at all.

The demand for improvement did not relate toage, but within the "wanting improvement" groupelderly subjects were less prepared to take additionaltrouble (p<0.(X)4)(Figure 5).

Implant treatment

For subjects aged 67 or over the most frequentreason against implants was "I am too old" or "it isnot worthwhile any more", whereas subjects youngerthan 67 often claimed to be "content with theirpresent state". Five subjects, with an average age of57.2, were not suitable for implants because the

I'tilicnls' level olcofuirti :iU

tcjeitinn cil Ilii' lin|'ltint

piiMiNc (livippiiintiiicnt ul I'IIILUHU

inject 1 nil K

IIIDC neceiMiry for ihe ircalnicrii

II "forcinn IxHly (ecling'

the L'osts iif Ihc ireiitnieni

extensive oral hygiene

insufricienl cllnicnl c^pcricnio wiih

X-rays being Uiken

|vcr> tiiucli H a Itulc • ! don'l know ^ nol

Figure 7. Quantified and specified fear.s and scepticismsagainst an imptanl treatment. Only patients who were eligiblefor an implant treatment were involved (n=33)

extraction of the last teeth was less than 12 monthago. All these subjects, however, requested implanttreatment after the one year period (Figure 6).

From the examination, implants seemed possiblefor 33 patients but some of these had concern ornegative attitudes, of which the most frequentconcerns were "fear of rejection", the "operation"and a "possible disappointment about the outcome ofthe treatment". In contrast very few subjects mindedpractising "comprehensive oral hygiene" or "x-rays"being taken. There was also little concern about theamount and duration of "clinical experience" usingthis method or the "costs" of the treatment (Figure7). Fear and scepticism against implants, quantifiedas "Implantation Index" did not relate to age, clini-cal findings or the Denture Satisfaction Index (DSI).However, those subjects who wanted an improve-ment of their dentures in any case were younger(p<0.01) and showed a higher Implantation Index(p<0.04) than those subjects who wanted improve-ment but were not prepared to take trouble. A similarbut non significant difference was found in those

I am icx>o(d

ii I) not wonhKhjIe an> morE

my bane ii nol tujtaUe

ihe ntk. r5 (oo high

It isioonpensive

I an) afrad of a 'lorctgn bod) feeling'

I am •fraid of an opcralum

tray be later 'pcm exit >I ain conicnl wtiih prcient U3le ̂ j HI am wepucaJ

Implani ireatmeni is. in pnnciple.i l possible ^ ncH possible

auntier at poneiUi under 67 yean

5 Ml i ;number of paiients at 67 yean or over

Figure 6. Frequency of reasons against an implant treatment(several answers possible). Patients with an age of over orequal to 67 years and under were distinguished

Do you wani j n improvement of your dentures?

uncondiliotially yc

yes. if ediy

indecisive

no. ncil necessary

no, not at

pS0.04

p S 0.01

Figure 8. Objections concerning an implant treatment -quantified as Implantation Index (I!) related to the intensityof improvement-demand

Gerodontology

Denture satisfaction and improvement demand

iods who did nol wiinl :m improvement (Figure 8).

Discussion

The results provide sonic detail within the generaltrend that expectations and dernand for prostheticcare decline with age. It seems that elderly patientsare more likely to tolerate poorly fitting dentures. Onone hand this might be due to unconscious adapta-tion to the insidious progression of the functionalloss** but could, on the other hand, be due to aresignation concerning the process of ageing^'" andtherefore loose dentures might be considered as justone amongst other handicaps in general health withwhich one has to cope when ageing. The old personsdo not like any changes" and they may prefer toaccept functional impairment rather than changes inappearance, function or shape that occur with newdentures. Those patients who wish an improvementof their dentures, but were not prepared to taketrouble in terms of time or costs {"yes, if easy"), wereon average 8 years older than patients who desiredan improvement of their dentures "unconditionally".This diminished improvement-demand with age alsoshows in the frequency of reasons against implantssuch as "I am too old" or "it is not worthwhile anymore".

With the exception of dementia the contra-indications for implants were not found to be worsefor the older patients: given mental clearness, apositive attitude and reasonable general health thereis no reason against implant treatment to improve lifequality even at an advanced age. However, withageing the local oral findings tend to be less favour-able. Therefore advice on implants should beconsidered in early edentulism, even when oralconditions subjectively do not necessitate dentureimprovement at this stage. As a physiological advan-tage, the diminished loading of the alveolar ridgesseems to reduce their atrophy'- and restorations ofhigh functional quality could more often be main-tained into old age.

However, caution is necessary when edentulouspatients' complaints about the present dentures donot coincide with the clinical findings. To excludepsychological intolerance of dentures those patientsshould first be provided conventional treatment.

Although no general relationship between thedemand for denture improvement and fear andscepticism towards implants was found, within thegroup of patients who desire denture improvementthose subjects who wanted it unconditionally showeda higher Implantation Index (II). Their tribulation

seems to overshadow most concerns about possiblerisks and (rouble of the offered treatment. Bycontrast, those patients who did want an improve-ment only ifeasy, showed a lower Implantation Index(II). In this group the lower motivation for dentureimprovement might possibly be due to Ihe higheraverage age of subjects. The most frequent objectionwas concerned with the possibility of rejection of theimplants and the operation itself. This seemsrealistic because the insertion of a foreign body in abiological system can elicit reactions which might bedifficult to infiuence and osseointegration cannot beguaranteed. Likewise the discomfort of the operationitself cannot be denied - even when performed withcare. In contrast, the fear of disappointment from theoutcome of the treatment seems not to be realistic.Although Davis and co-workers'^ described theexpectations of edentulous patients towards replace-ment dentures as unrealistically high, there was stilla significant increase in denture satisfaction after thetreatment. These authors claim that both, functionalimprovement of the new dentures and the patient'spayment were responsible for their satisfaction.

Conclusions

From clinical examination and the use of question-naires in a sample of 64 edentate subjects of twodental schools it can be concluded that:

• The DSI proved an easy questionnaire whichprovides a numerate measure for denture satisfac-tion.

• By using the DSI in combination with theimprovement demand patients' attitude towardstreatment can be measured and contributes to pre-scription of treatment.

• Although denture satisfaction does not appear tobe generally related to age, younger patients seemmore likely to be dissatisfied with loose lowerdentures.

• With patients who wish denture improvement,those who are older are less prepared to acceptcomprehensive treatment.

• Scepticism concerning implant treatment appearsnot related to age, but patients keen for dentureimprovement tend to be younger and are lesslikely to be worried about implant treatment.

• The lower acceptance of treatment by olderpatients indicates the need for early considerationof adequate treatment to secure quality of lifebenefit and mastication later in life.

Volume 11, No.l

2 Mullci. Wiihl ;itul l-uhr

Rcfcroncos

1. Ziirb (; A, Schmilt A, The longitudimilcitcctivcncss of osseoiiUcgr;iled dental implants: theToronto study. Part II; The prosllielic icsiihs. J ProsthctDent lW0i64:h3-M,

2, Hoosstniteii J. Liimers L M, i';itienl satisfactionatter insertion of an osscointegraled implant bridge, 7 Ortj/Rehab 1987; 14:481-187.

3 Gregory M, Murphy \V M, Scott J, Watson C J,Reeve P E A clinical study of the Branemark dentalimplant system. Br Dent J 1990; 168:18-23.

4 Blomberg S, Lindquist L VV. Psychologicalreactions to edentulousness and treatment withjawbone- anchored bridges. Acta Psychiatr Seand 1983;68:251-262.

?. Breustedt A. Gerontologische und geriatrischeProbleme in der Stomatologie. Teil II: Auswirkungenaltersbedingter psychischer und soziuler Eintiusse auf dieprothetische Therapie. Dtsch Zahnarztl Z 1975;30:565-569.

6. Albrektson T. Blomberg S. Branemark A,Carlsson G E. Edentulousness - an oral handicap. Palientreactions to treatment with jawbone-anchored prostheses.J Oral Rehab 1987; 14:503-511.

7 Breustedl A. Physiological and social factors of im-portance for the older edentulous patient. Int Dent J 1979;29:276-284.

8. Atwoocl D A. Postextraction changes in the adultmandible as illuslralcd hy microradiographs of mid.sagittalsections and serial cephalometric roentgcnograms. JPro.sthet Dent 1963; 13:810-824.

9. KorduncrC, Marken K-E, Ke-examination of com-plete denture patients. II. Status and need of treatment aftertwo years. Acta Odont Scand 1967; 25:373-381.

10. Mojon P, MacEntee M 1. Discrepancy between needfor prosthodontic treatment and complaints in an elderlyedentulous population. Coniniunity Dent Oral Epidemiol1992; 20:48-52.

1 1. Tanzer G. Aspekte der prothetischen Versorgungalter Menschen. Zahnarztl Rundsch 1972; 81:709-716.

12. Jaeobs R, Schotte A, van Steenbergbe D, QuirynenM, Naert I. Posterior jaw bone resorption inosseointegrated implant-supported overdentures. ClinOral Impi Res 1992; 3:63-70.

1 3 Davis E L, Albino J E, Tedeseo L A, Portenoy B S,Ortman L F. Expectations and satisfaction of denture pa-tients in a university clinic. 7 Pra5//!e/Z)e/i/ 1986;55: 59-63.

Address for correspondence: Dr. Frauke Muller, University of Mainz, Poiiklinik furZahnarztliche Prothetik, Augustusplatz2. 55131 Mainz. Germany

Acknowledgement: The authors would like to thank Prof, Dr, Bernd Koeck, Head of the Department of Prosthetic Den-tistry. University of Bonn, for provision of facilities.

Gerodontology