The further development and validation of the Liverpool Oral Rehabilitation Questionnaire (LORQ) version 3: A cross-sectional survey of patients referred to a dental hospital for removable

232 Volume 99 Issue 3

The Journal of Prosthetic Dentistry

FJ, Verdonschot N, Creugers NH. A compar-ison of fatigue resistance of three materials for cusp-replacing adhesive restorations. J Dent 2006;34:19-25. Epub 2005 Jun 2.

49.Dalpino PH, Francischone CE, Ishikiriama A, Franco EB. Fracture resistance of teeth directly and indirectly restored with com-

posite resin and indirectly restored with ceramic materials. Am J Dent 2002;15:389-94.

50.Reeh ES, Douglas WH, Messer HH. Stiffness of endodontically-treated teeth related to restoration technique. J Dent Res 1989;68:1540-4.

Corresponding author:Dr Gianluca PlotinoVia Eleonora Duse, 2200197 Rome ITALYFax: +39068072289E-mail: [email protected]

Copyright © 2008 by the Editorial Council for

The Journal of Prosthetic Dentistry.

Plotino et al

Clinical ImplicationsThe ongoing validation of the LORQ questionnaire affords the opportunity for more appropriate inquiry into the benefits of oral rehabilitation in patients following head and neck cancer. This tool can be used within a research setting to better assess interventions.

Statement of problem. The Liverpool Oral Rehabilitation Questionnaire (LORQ) is a health-related quality of life instrument assessing the impact of oral rehabilitation on patients’ health-related quality of life (HRQOL) following treatment for oral cancer. The small number of patients wearing prostheses in previous studies limited the validation of the denture/denture satisfaction part of the questionnaire.

Purpose. The purpose of this study was to further validate the LORQ by obtaining HRQOL data from patients requir-ing replacement dentures.

Material and methods. The LORQv3, together with items assessing mood and anxiety, was administered with the Oral Health Impact Profile 14-item (OHIP-14) questionnaire to 104 consecutive patients, between the ages of 40 and 79, referred by their general dentists to the department of prosthodontics at the Liverpool University Dental Hospital for replacement of removable prostheses between November 2004 and June 2005. The Mann-Whitney and Krus-kal-Wallis tests compared scores between patient groups. Internal consistency was measured by Cronbach’s alpha. Spearman’s correlation investigated associations between items on the LORQv3 and items from the OHIP-14. Test-retest was measured by the kappa coefficient, weighted by applying standard weights according to the number of categories in error.

Results. Patients wearing complete dentures in 1 or both arches generally scored worse for oral function and mandib-ular denture problems/satisfaction than patients wearing removable partial dentures. Thirty-three percent of patients were somewhat or extremely depressed, 25% were anxious or very anxious, and 15% were both depressed and anxious.

Conclusions. The denture section of the LORQv3 identified expected differences among various patient subgroups in this cohort confirmed by similar findings for the OHIP-14 and the literature. Thus, this part of the LORQv3 re-ferring to dentures and patient satisfaction demonstrated good construct and criterion validity. (J Prosthet Dent 2008;99:233-242)

The further development and validation of the Liverpool Oral Rehabilitation Questionnaire (LORQ) version 3: A cross-sectional survey of patients referred to a dental hospital for removable prostheses replacement

Adrian Pace-Balzan, BChD, MPhil,a Christopher J. Butterworth, BDS (Hons), MPhil,b Luke J. Dawson, BSc (Hons), BDS (Hons), PhD,c Derek Lowe, MSc, CStat,d and Simon N. Rogers, BDS, MBChB, MDe

Edinburgh Dental Institute, Edinburgh, UK; Liverpool University Dental Hospital, Liverpool, UK; University Hospital Aintree, Liverpool, UK

aSpecialist Registrar, Restorative Dentistry, Edinburgh Dental Institute.bConsultant, Restorative Dentistry, Oral Rehabilitation, Liverpool University Dental Hospital.cSenior Lecturer in Oral Surgery, Liverpool University Dental Hospital.dMedical Statistician, Mossley, Cheshire, UK.eConsultant, Oral and Maxillofacial Surgery, University Hospital Aintree.

Pace-Balzan et al

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235March 2008

Oral and oropharyngeal cancer has a major impact on the physical, psychological, and social well-being of affected individuals. Survival is the patients’ initial concern,1 but in the long term, there is a shift towards im-proving and maintaining a health-re-lated quality of life (HRQOL). For pa-tients treated for oral cancer, a major concern is their ability to masticate, speak, and swallow.2 Oral rehabilita-tion attempts to address such issues and is specifically aimed at improving and enhancing the HRQOL of patients. As no suitable valid questionnaire was available in the 1990s, the oral reha-bilitation team in Aintree, Liverpool, designed the self-administered LORQ, with the aims of (1) assessing the im-pact of oral rehabilitation following treatment for head and neck cancer, (2) assessing the outcome of oral re-habilitation on HRQOL, (3) aiding patient treatment selection, and (4) evaluating the efficacy of outcome fol-lowing oral rehabilitation. The LORQ was first published in 2004 with en-couraging results.3 Subsequently, a second version of the questionnaire, the LORQv2, was piloted to 57 pa-tients, resulting in the current version, version 3, of the LORQ. The LORQv3 consists of 40 items divided into 2 pri-mary sections, the first relating to oral function, oro-facial appearance, and social interaction, and the second section relating to prostheses and pa-tient denture/prosthetic satisfaction. The changes made to the original versions of the LORQ included addi-tional items, namely, (1) trismus (1 item), (2) difficulty with mastication (1 item), (3) appearance (3 items), (4) denture status (1 item), (5) dental status (1 item), (6) implant status (1 item), and (7) a free-text item invit-ing patients to identify issues not ad-equately addressed by the question-naire. Changes were made following discussions between members of the oral rehabilitation team and prior to administration of the LORQ.

The LORQv3 has been used with patients attending general dental practices for routine dental care and

patients attending the oral rehabilita-tion clinic in Liverpool. These stud-ies show enough support for the first part of the LORQv3 as a valid tool, but data were lacking for the section referring to dentures and denture sat-isfaction.4 Hence, the aim of this study was to further validate the LORQv3 by obtaining data from a cross-sec-tional survey of patients attending the department of prosthodontics at the Liverpool University Dental Hospital (LUDH). The null hypotheses were that (1) the LORQv3 would not iden-tify differences between subgroups of patients attending the LUDH for replacement dentures, and (2) the LORQv3 would not identify differenc-es between data from the cancer/oral rehabilitation cohort and reference data obtained from the prosthodon-tic and GDP cohorts.

MATERIAL AND METHODS

Ethical approval was obtained from the Liverpool LREC (04/Q1502/78). This cross-sectional study surveyed patients referred from general den-tal practice to the department of prosthodontics, LUDH, for replace-ment dentures from November 2004 to June 2005. Patients wearing com-plete and/or partial removable den-tures were approached. Only patients between the ages of 40 and 79 were included to closely match the age dis-tribution of patients with oral cancer. Patients were excluded if they (1) did not wear dentures, (2) wore implant-supported prostheses, (3) had a pre-vious history of oral cancer, (4) were referred for other prosthodontic/den-tal problems, and (5) were not profi-cient in the English language.

Patients were identified from refer-ral letters, and eligible patients were approached by 1 of the authors either before or at the end of consultation. Following a brief explanation of the study, patients were given an informa-tion sheet, study protocol, and a con-sent form. Consenting patients were given 2 questionnaires to complete at the clinic, the LORQv3 and the OHIP-

14.5 To assess test-retest reliability, a further set of questionnaires was given to the subjects to complete 2 weeks later at home.

The LORQv3 (available at www.headandneckcancer.co.uk)consists of 40 items. The first 17 items assess issues of oral function, oro-facial ap-pearance, and social interaction. Re-maining items assess issues relating to prostheses and patient denture/pros-thetic satisfaction. Items refer to prob-lems or symptoms experienced during the previous week and are rated on a 1 to 4 Likert scale, from “never” (1) to “always” (4). There is also a free-text invitation for patients to state issues not covered by the questionnaire.

The mood and anxiety questions from the head and neck cancer-spe-cific University of Washington Qual-ity of Life questionnaire version 4 (UWQOLv4)2 were added and adapt-ed to the LORQv3 for this study. Such items provide a psychological profile of the cohort being studied and a measure of anxiety and depression “during the past week.” These items were added as there is evidence that negative mood is prevalent in this cohort of patients6,7 and this can ad-versely impact the HRQOL.8 All men-tion of cancer was removed from the items. Mood was measured as: “my mood has been excellent and unaf-fected”; “my mood was generally good and only occasionally affect-ed”; “I was neither in a good mood nor depressed”; “I was somewhat depressed”; or “I was extremely de-pressed.” Anxiety was measured as: “I was not anxious”; “I was a little anx-ious”; “I was anxious”; or “I was very anxious.”

The OHIP-145 is a shortened ver-sion of the original 49-item OHIP questionnaire developed by Slade and Spencer. It aims to provide a compre-hensive measure of dysfunction, dis-comfort, and disability attributable to oral conditions, as well as assess-ing patient-perceived social impact of oral disorders. The 14 items form 7 subscales: functional limitation, phys-ical pain, psychological discomfort,

physical disability, psychological disa-bility, social disability, and handicap. There are 2 items per subscale, each item scored on a Likert scale from (1) “never” to (5) “very often.” Results for the prosthodontic cohort were com-pared to reference data from general dental practices and from the oral re-habilitation clinic. The general den-tal practice cohort consisted of 349 patients attending 6 dental practices for routine dental care. The patients were between the ages of 40 and 79, reflecting the age distribution of most patients with oral cancer. The oral re-habilitation cohort consisted of 182 consecutive cancer and noncancer-ous patients who attended the oral rehabilitation clinic between January 2000 and April 2004. Comparisons between these patient groups have been published, 4 and it was demon-strated that (1) patients attending GDPs scored appreciably better on most items in the LORQv3, and (2) the LORQv3 discriminated between cancer and noncancer oral rehabilita-tion patients in items such as degluti-tion, mastication, trismus, drooling, and food clearance.

For statistical analysis, patients were put into 3 groups: (1) group CD included patients wearing complete dentures in both arches, (2) group COMB consisted of patients wearing a combination of complete dentures in 1 arch opposed by either a partial denture or no denture on the other, and (3) group PD were patients wear-ing partial dentures in 1 or both arch-es. The expectation was that there would be differences in the LORQv3 among the patient groups.10,11

Questionnaire responses were on an ordinal scale. The Mann-Whit-ney test was used to compare scores between 2 patient groups and the Kruskal-Wallis test between 3 groups. The internal consistency of LORQv3 items was measured by Cronbach’s al-pha. Spearman’s correlation was used to investigate associations between items on the LORQv3 and items from the OHIP-14. Item agreement in test-retest comparisons was measured by

the kappa coefficient weighted by ap-plying standard weights according to the number of categories in error. Kap-pa values of 0.41 to 0.60 are said to indicate “moderate” agreement, 0.61 to 0.80, “good” agreement, and over 0.80, “very good” agreement. Sta-tistical significance was regarded as α=.05. Borderline results (.05<α<.10) are commented on.

RESULTS

There were a total of 59 prosth-odontic consultation clinics dur-ing this period (from November 18, 2004, through June 6, 2005). One hundred and four of the 116 patients eligible for recruitment participated in the study. The median age of this cohort was 66 years, range 40-79, with 32% (33) men and 68% (71) women. The maxillary dental status was edentulous for 69% (72) with all wearing complete dentures, and partially dentate for 31% (32) with 28 wearing partial dentures, and 4 with no dentures. Mandibular dental status was edentulous for 49% (51) with 50 wearing complete dentures and 1 no dentures, partially dentate for 44% (46) with 25 wearing remov-able partial dentures, 21 no dentures, and dentate for 7% (7). For further analysis, patients were grouped into group CD, patients wearing complete dentures in both arches (46); group COMB, patients wearing a combina-tion of complete dentures in 1 arch opposed by either a removable par-tial denture or no denture in the other (30); and group PD, patients wearing, at most, removable partial dentures in 1 or both arches (28).

The first 17 items of the LORQv3 assessed issues relating to oral func-tion, oro-facial appearance, and social interaction, and applied to all patients (Table I). Patients with complete max-illary or mandibular dentures or both (patient groups CD and COMB) con-sistently scored worse than those with partial or no dentures (group PD) on most items; the most notable being in relation to pain when masticating

(item 2) and food particles sticking inside the cheeks (item 7). There were no significant differences between groups CD and COMB for the first 17 items of the LORQv3.

The second part of the LORQv3 assessed the social impact of prosthe-ses as well as patient denture satisfac-tion (Table II). Groups CD and COMB refused more dinner invitations (item 21) because of their dentures/im-plant-retained teeth than group PD. There were similar trends for being more embarrassed about conversing (item 20) and finding it difficult to open their mouths (item 23) because of dentures/implant-retained teeth. Little difference was noted for item 22 (loss of self-confidence because of embarrassment about dentures/im-plant retained teeth). For items 26 to 31, referring to maxillary dentures or implant-retained teeth, group CD pa-tients (complete maxillary and man-dibular dentures) generally felt more satisfied and secure with their maxil-lary dentures/implant-retained teeth than groups COMB and PD, and were less likely to find food collecting under them. Patients with removable partial dentures (group PD) were the most likely to remove their maxillary partial dentures for eating. For items 34 to 39, referring to mandibular dentures or implant-retained teeth groups, CD and COMB generally scored worse than group PD (at most, partial den-tures). For item 37, group COMB pa-tients were the most likely to remove their mandibular prostheses for eat-ing.

Group PD patients generally had fewer problems on the OHIP-14 for physical pain, physical disability, psy-chological discomfort, and psycholog-ical disability (Table III). Cronbach’s alpha for internal consistency was .89 for the first 17 LORQv3 items, .86 for items 20 to 23, .81 for items 26 to 31, .84 for items 34 to 39, and .95 for the OHIP-14.

The first 16 items of the LORQ were well answered, with 2 patients, at most, failing to complete any 1 item, and 90% of the patients provid-

Pace-Balzan et al Pace-Balzan et al



235March 2008

Oral and oropharyngeal cancer has a major impact on the physical, psychological, and social well-being of affected individuals. Survival is the patients’ initial concern,1 but in the long term, there is a shift towards im-proving and maintaining a health-re-lated quality of life (HRQOL). For pa-tients treated for oral cancer, a major concern is their ability to masticate, speak, and swallow.2 Oral rehabilita-tion attempts to address such issues and is specifically aimed at improving and enhancing the HRQOL of patients. As no suitable valid questionnaire was available in the 1990s, the oral reha-bilitation team in Aintree, Liverpool, designed the self-administered LORQ, with the aims of (1) assessing the im-pact of oral rehabilitation following treatment for head and neck cancer, (2) assessing the outcome of oral re-habilitation on HRQOL, (3) aiding patient treatment selection, and (4) evaluating the efficacy of outcome fol-lowing oral rehabilitation. The LORQ was first published in 2004 with en-couraging results.3 Subsequently, a second version of the questionnaire, the LORQv2, was piloted to 57 pa-tients, resulting in the current version, version 3, of the LORQ. The LORQv3 consists of 40 items divided into 2 pri-mary sections, the first relating to oral function, oro-facial appearance, and social interaction, and the second section relating to prostheses and pa-tient denture/prosthetic satisfaction. The changes made to the original versions of the LORQ included addi-tional items, namely, (1) trismus (1 item), (2) difficulty with mastication (1 item), (3) appearance (3 items), (4) denture status (1 item), (5) dental status (1 item), (6) implant status (1 item), and (7) a free-text item invit-ing patients to identify issues not ad-equately addressed by the question-naire. Changes were made following discussions between members of the oral rehabilitation team and prior to administration of the LORQ.

The LORQv3 has been used with patients attending general dental practices for routine dental care and

patients attending the oral rehabilita-tion clinic in Liverpool. These stud-ies show enough support for the first part of the LORQv3 as a valid tool, but data were lacking for the section referring to dentures and denture sat-isfaction.4 Hence, the aim of this study was to further validate the LORQv3 by obtaining data from a cross-sec-tional survey of patients attending the department of prosthodontics at the Liverpool University Dental Hospital (LUDH). The null hypotheses were that (1) the LORQv3 would not iden-tify differences between subgroups of patients attending the LUDH for replacement dentures, and (2) the LORQv3 would not identify differenc-es between data from the cancer/oral rehabilitation cohort and reference data obtained from the prosthodon-tic and GDP cohorts.

MATERIAL AND METHODS

Ethical approval was obtained from the Liverpool LREC (04/Q1502/78). This cross-sectional study surveyed patients referred from general den-tal practice to the department of prosthodontics, LUDH, for replace-ment dentures from November 2004 to June 2005. Patients wearing com-plete and/or partial removable den-tures were approached. Only patients between the ages of 40 and 79 were included to closely match the age dis-tribution of patients with oral cancer. Patients were excluded if they (1) did not wear dentures, (2) wore implant-supported prostheses, (3) had a pre-vious history of oral cancer, (4) were referred for other prosthodontic/den-tal problems, and (5) were not profi-cient in the English language.

Patients were identified from refer-ral letters, and eligible patients were approached by 1 of the authors either before or at the end of consultation. Following a brief explanation of the study, patients were given an informa-tion sheet, study protocol, and a con-sent form. Consenting patients were given 2 questionnaires to complete at the clinic, the LORQv3 and the OHIP-

14.5 To assess test-retest reliability, a further set of questionnaires was given to the subjects to complete 2 weeks later at home.

The LORQv3 (available at www.headandneckcancer.co.uk)consists of 40 items. The first 17 items assess issues of oral function, oro-facial ap-pearance, and social interaction. Re-maining items assess issues relating to prostheses and patient denture/pros-thetic satisfaction. Items refer to prob-lems or symptoms experienced during the previous week and are rated on a 1 to 4 Likert scale, from “never” (1) to “always” (4). There is also a free-text invitation for patients to state issues not covered by the questionnaire.

The mood and anxiety questions from the head and neck cancer-spe-cific University of Washington Qual-ity of Life questionnaire version 4 (UWQOLv4)2 were added and adapt-ed to the LORQv3 for this study. Such items provide a psychological profile of the cohort being studied and a measure of anxiety and depression “during the past week.” These items were added as there is evidence that negative mood is prevalent in this cohort of patients6,7 and this can ad-versely impact the HRQOL.8 All men-tion of cancer was removed from the items. Mood was measured as: “my mood has been excellent and unaf-fected”; “my mood was generally good and only occasionally affect-ed”; “I was neither in a good mood nor depressed”; “I was somewhat depressed”; or “I was extremely de-pressed.” Anxiety was measured as: “I was not anxious”; “I was a little anx-ious”; “I was anxious”; or “I was very anxious.”

The OHIP-145 is a shortened ver-sion of the original 49-item OHIP questionnaire developed by Slade and Spencer. It aims to provide a compre-hensive measure of dysfunction, dis-comfort, and disability attributable to oral conditions, as well as assess-ing patient-perceived social impact of oral disorders. The 14 items form 7 subscales: functional limitation, phys-ical pain, psychological discomfort,

physical disability, psychological disa-bility, social disability, and handicap. There are 2 items per subscale, each item scored on a Likert scale from (1) “never” to (5) “very often.” Results for the prosthodontic cohort were com-pared to reference data from general dental practices and from the oral re-habilitation clinic. The general den-tal practice cohort consisted of 349 patients attending 6 dental practices for routine dental care. The patients were between the ages of 40 and 79, reflecting the age distribution of most patients with oral cancer. The oral re-habilitation cohort consisted of 182 consecutive cancer and noncancer-ous patients who attended the oral rehabilitation clinic between January 2000 and April 2004. Comparisons between these patient groups have been published, 4 and it was demon-strated that (1) patients attending GDPs scored appreciably better on most items in the LORQv3, and (2) the LORQv3 discriminated between cancer and noncancer oral rehabilita-tion patients in items such as degluti-tion, mastication, trismus, drooling, and food clearance.

For statistical analysis, patients were put into 3 groups: (1) group CD included patients wearing complete dentures in both arches, (2) group COMB consisted of patients wearing a combination of complete dentures in 1 arch opposed by either a partial denture or no denture on the other, and (3) group PD were patients wear-ing partial dentures in 1 or both arch-es. The expectation was that there would be differences in the LORQv3 among the patient groups.10,11

Questionnaire responses were on an ordinal scale. The Mann-Whit-ney test was used to compare scores between 2 patient groups and the Kruskal-Wallis test between 3 groups. The internal consistency of LORQv3 items was measured by Cronbach’s al-pha. Spearman’s correlation was used to investigate associations between items on the LORQv3 and items from the OHIP-14. Item agreement in test-retest comparisons was measured by

the kappa coefficient weighted by ap-plying standard weights according to the number of categories in error. Kap-pa values of 0.41 to 0.60 are said to indicate “moderate” agreement, 0.61 to 0.80, “good” agreement, and over 0.80, “very good” agreement. Sta-tistical significance was regarded as α=.05. Borderline results (.05<α<.10) are commented on.

RESULTS

There were a total of 59 prosth-odontic consultation clinics dur-ing this period (from November 18, 2004, through June 6, 2005). One hundred and four of the 116 patients eligible for recruitment participated in the study. The median age of this cohort was 66 years, range 40-79, with 32% (33) men and 68% (71) women. The maxillary dental status was edentulous for 69% (72) with all wearing complete dentures, and partially dentate for 31% (32) with 28 wearing partial dentures, and 4 with no dentures. Mandibular dental status was edentulous for 49% (51) with 50 wearing complete dentures and 1 no dentures, partially dentate for 44% (46) with 25 wearing remov-able partial dentures, 21 no dentures, and dentate for 7% (7). For further analysis, patients were grouped into group CD, patients wearing complete dentures in both arches (46); group COMB, patients wearing a combina-tion of complete dentures in 1 arch opposed by either a removable par-tial denture or no denture in the other (30); and group PD, patients wearing, at most, removable partial dentures in 1 or both arches (28).

The first 17 items of the LORQv3 assessed issues relating to oral func-tion, oro-facial appearance, and social interaction, and applied to all patients (Table I). Patients with complete max-illary or mandibular dentures or both (patient groups CD and COMB) con-sistently scored worse than those with partial or no dentures (group PD) on most items; the most notable being in relation to pain when masticating

(item 2) and food particles sticking inside the cheeks (item 7). There were no significant differences between groups CD and COMB for the first 17 items of the LORQv3.

The second part of the LORQv3 assessed the social impact of prosthe-ses as well as patient denture satisfac-tion (Table II). Groups CD and COMB refused more dinner invitations (item 21) because of their dentures/im-plant-retained teeth than group PD. There were similar trends for being more embarrassed about conversing (item 20) and finding it difficult to open their mouths (item 23) because of dentures/implant-retained teeth. Little difference was noted for item 22 (loss of self-confidence because of embarrassment about dentures/im-plant retained teeth). For items 26 to 31, referring to maxillary dentures or implant-retained teeth, group CD pa-tients (complete maxillary and man-dibular dentures) generally felt more satisfied and secure with their maxil-lary dentures/implant-retained teeth than groups COMB and PD, and were less likely to find food collecting under them. Patients with removable partial dentures (group PD) were the most likely to remove their maxillary partial dentures for eating. For items 34 to 39, referring to mandibular dentures or implant-retained teeth groups, CD and COMB generally scored worse than group PD (at most, partial den-tures). For item 37, group COMB pa-tients were the most likely to remove their mandibular prostheses for eat-ing.

Group PD patients generally had fewer problems on the OHIP-14 for physical pain, physical disability, psy-chological discomfort, and psycholog-ical disability (Table III). Cronbach’s alpha for internal consistency was .89 for the first 17 LORQv3 items, .86 for items 20 to 23, .81 for items 26 to 31, .84 for items 34 to 39, and .95 for the OHIP-14.

The first 16 items of the LORQ were well answered, with 2 patients, at most, failing to complete any 1 item, and 90% of the patients provid-




237March 2008

1. Did you experience difficulty with chewing? *

2. Did you have pain when you chew? ***

3. Did you experience difficulty with swallowing solids? *

4. Did you experience difficulty with swallowing liquids?

5. Did food particles collect under your tongue? *

6. Did food particles stick to your palate?

7. Did food particles stick inside your cheeks? **

8. Did you have mouth dryness?

9. Did you have problems with drooling?

10. Did you experience problems with speech?

11. Were you upset by your facial appearance?

12. Were you upset by the appearance of your mouth?

13. Were you upset by the appearance of your lips?

14. Were you upset by the appearance of your teeth?

15. Did your chewing ability affect your social life? *

16. Did your chewing ability influence your choice of foods?

17. Did you experience difficulty with opening your mouth?

3.0

2.6

1.8

1.2

1.9

3.0

2.1

2.3

1.7

2.0

2.1

2.2

2.1

2.1

2.5

3.0

1.7

67

43

20

2

15

70

31

33

15

28

32

31

32

33

43

67

16

CDn=43-46

mean % mean % mean %

3.2

2.4

1.8

1.3

2.0

2.9

2.0

2.0

1.6

1.9

2.0

2.1

1.7

2.4

2.9

3.3

1.5

73

38

23

3

32

63

20

23

10

23

33

40

23

43

67

80

14

COMBn=28-30

2.6

1.6

1.4

1.3

1.5

2.6

1.5

1.9

1.4

1.9

1.6

1.7

1.5

2.3

2.3

2.6

1.4

43

11

11

7

7

46

7

21

4

15

18

26

11

41

39

54

4

PDn=25-28

Kruskal-Wallis test for differences between 3 groups: *** P<.01, ** .01<P<.05, * .05<P<.10 No significant differences between groups CD and COMB at P<.05 (Mann-Whitney test)

Table I. First 17 LORQ items assessing issues related to oral function, oro-facial appearance, and social interaction. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Table gives mean score and % of patients who said “often” or “always”

ing complete information. Item 17, dealing with trismus, was left blank by 8 patients, perhaps due to its lo-cation on the questionnaire. For the OHIP-14, 88% of patients provided complete information. Only 2 pa-tients did not answer the mood and anxiety questions. Complete answers were given by 96% for LORQ items 20 to 23, 85% for items 26 to 31, and 84% for items 34 to 39.

Relative to patients in an oral reha-bilitation clinic setting, the patients in the current study had more difficulty

with mastication, pain on mastication, and food particles sticking under the palate (Table IV). The patients also re-ported more problems on the OHIP-14 in regard to physical pain, physical disability, psychological discomfort, and psychological disability (Table V). Patients seeing a general dental prac-titioner for routine appointments had the fewest problems as measured by the LORQ (Table IV).

All but 4 of 462 possible Spear-man correlation coefficients between LORQv3 and OHIP-14 Likert-rated

items were positive, with a median of 0.38 and interquartile range (IQR) of 0.27 to 0.50. Correlations with the OHIP-14 were highest for LORQ items 20 to 23 asking about prosthe-ses in general (median correlation 0.55; IQR 0.50 to 0.63), while the lowest correlations were for items 26 to 31 concerning maxillary prosthe-ses (median 0.26, IQR 0.19 to 0.37). Correlations between the OHIP-14 and items 34 to 39 concerning man-dibular prostheses (median 0.38, IQR 0.27 to 0.50) were higher than for

If dentures or implant-retained teeth (YES to question 24, 25, 32, or 33):

20. Were you embarrassed about conversing because of your dentures/implant-retained teeth? *

21. Did you refuse dinner invitations because of embarrassment about your dentures/implant-retained teeth? **

22. Did you feel loss of self-confidence because of embarrassment about your dentures/implant-retained teeth?

23. Did you find it difficult to open your mouth because of your dentures/implant-retained teeth?

2.5

2.3

2.6

2.1

45

43

55

32

2.5

2.3

2.7

2.0

53

50

57

30

2.0

1.6

2.5

1.6

19

23

52

20

CD COMB PD

Kruskal-Wallis test for differences between 3 groups: *** P<.01, ** .01<P<.05, * .05<P<.10

n=44mean % mean % mean %

n=30 n=25-27

If upper dentures or implant-retained teeth (YES to question 24 or question 25):

26. Were you dissatisfied with your upper denture/implant-retained teeth? ***

27. Did you upper denture/implant-retained teeth cause soreness or ulceration of the gum?

28. Did you find food particles collecting under yourupper denture/implant-retained teeth? ***

29. Did you take out your upper denture/implant-retained teeth for eating? ***

30. Did you feel insecure with your upper denture/implant-retained teeth? *

31. Were you worried that your upper denture/implant-retained teeth might fall out? *

2.2

1.9

2.4

1.2

2.0

2.0

33

22

38

7

31

35

3.1

2.3

3.1

1.5

2.7

2.8

69

42

65

12

58

58

3.1

1.9

3.1

2.1

2.6

2.5

72

25

72

36

52

46

3.4

2.8

3.4

1.8

3.1

2.8

83

53

81

23

69

58

3.2

3.1

3.6

2.6

3.2

2.5

67

71

86

55

75

52

2.3

1.4

1.8

2.0

2.0

1.7

44

14

17

33

25

11

n=39-42mean % mean % mean %

n=26 n=24-25

If lower dentures or implant-retained teeth (YES to question 32 or question 33):

34. Were you dissatisfied with your lower denture/implant-retained teeth? **

35. Did your lower denture/implant-retained teeth cause soreness or ulceration of the gum? ***

36. Did you find food particles collecting under your lower denture/implant-retained teeth? ***

37. Did you take out your lower denture/implant-retained teeth for eating? **

38. Did you feel insecure with your lower denture/implant-retained teeth? **

39. Were you worried that your lower denture/implant-retained teeth might fall out? *


n=18-21 n=6-9

Table II. Remaining LORQ items referring to prostheses and patient satisfaction with prosthe-ses. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Mean score and % of patients who said “often” or “always”




237March 2008

1. Did you experience difficulty with chewing? *


3. Did you experience difficulty with swallowing solids? *


5. Did food particles collect under your tongue? *

6. Did food particles stick to your palate?

7. Did food particles stick inside your cheeks? **


9. Did you have problems with drooling?






15. Did your chewing ability affect your social life? *

16. Did your chewing ability influence your choice of foods?


3.0

2.6

1.8

1.2

1.9

3.0

2.1

2.3

1.7

2.0

2.1

2.2

2.1

2.1

2.5

3.0

1.7

67

43

20

2

15

70

31

33

15

28

32

31

32

33

43

67

16

CDn=43-46


3.2

2.4

1.8

1.3

2.0

2.9

2.0

2.0

1.6

1.9

2.0

2.1

1.7

2.4

2.9

3.3

1.5

73

38

23

3

32

63

20

23

10

23

33

40

23

43

67

80

14

COMBn=28-30

2.6

1.6

1.4

1.3

1.5

2.6

1.5

1.9

1.4

1.9

1.6

1.7

1.5

2.3

2.3

2.6

1.4

43

11

11

7

7

46

7

21

4

15

18

26

11

41

39

54

4

PDn=25-28

Kruskal-Wallis test for differences between 3 groups: *** P<.01, ** .01<P<.05, * .05<P<.10 No significant differences between groups CD and COMB at P<.05 (Mann-Whitney test)

Table I. First 17 LORQ items assessing issues related to oral function, oro-facial appearance, and social interaction. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Table gives mean score and % of patients who said “often” or “always”

ing complete information. Item 17, dealing with trismus, was left blank by 8 patients, perhaps due to its lo-cation on the questionnaire. For the OHIP-14, 88% of patients provided complete information. Only 2 pa-tients did not answer the mood and anxiety questions. Complete answers were given by 96% for LORQ items 20 to 23, 85% for items 26 to 31, and 84% for items 34 to 39.

Relative to patients in an oral reha-bilitation clinic setting, the patients in the current study had more difficulty

with mastication, pain on mastication, and food particles sticking under the palate (Table IV). The patients also re-ported more problems on the OHIP-14 in regard to physical pain, physical disability, psychological discomfort, and psychological disability (Table V). Patients seeing a general dental prac-titioner for routine appointments had the fewest problems as measured by the LORQ (Table IV).

All but 4 of 462 possible Spear-man correlation coefficients between LORQv3 and OHIP-14 Likert-rated

items were positive, with a median of 0.38 and interquartile range (IQR) of 0.27 to 0.50. Correlations with the OHIP-14 were highest for LORQ items 20 to 23 asking about prosthe-ses in general (median correlation 0.55; IQR 0.50 to 0.63), while the lowest correlations were for items 26 to 31 concerning maxillary prosthe-ses (median 0.26, IQR 0.19 to 0.37). Correlations between the OHIP-14 and items 34 to 39 concerning man-dibular prostheses (median 0.38, IQR 0.27 to 0.50) were higher than for

If dentures or implant-retained teeth (YES to question 24, 25, 32, or 33):

20. Were you embarrassed about conversing because of your dentures/implant-retained teeth? *

21. Did you refuse dinner invitations because of embarrassment about your dentures/implant-retained teeth? **

22. Did you feel loss of self-confidence because of embarrassment about your dentures/implant-retained teeth?

23. Did you find it difficult to open your mouth because of your dentures/implant-retained teeth?

2.5

2.3

2.6

2.1

45

43

55

32

2.5

2.3

2.7

2.0

53

50

57

30

2.0

1.6

2.5

1.6

19

23

52

20

CD COMB PD


n=44mean % mean % mean %

n=30 n=25-27

If upper dentures or implant-retained teeth (YES to question 24 or question 25):

26. Were you dissatisfied with your upper denture/implant-retained teeth? ***

27. Did you upper denture/implant-retained teeth cause soreness or ulceration of the gum?

28. Did you find food particles collecting under yourupper denture/implant-retained teeth? ***

29. Did you take out your upper denture/implant-retained teeth for eating? ***

30. Did you feel insecure with your upper denture/implant-retained teeth? *

31. Were you worried that your upper denture/implant-retained teeth might fall out? *

2.2

1.9

2.4

1.2

2.0

2.0

33

22

38

7

31

35

3.1

2.3

3.1

1.5

2.7

2.8

69

42

65

12

58

58

3.1

1.9

3.1

2.1

2.6

2.5

72

25

72

36

52

46

3.4

2.8

3.4

1.8

3.1

2.8

83

53

81

23

69

58

3.2

3.1

3.6

2.6

3.2

2.5

67

71

86

55

75

52

2.3

1.4

1.8

2.0

2.0

1.7

44

14

17

33

25

11


n=26 n=24-25

If lower dentures or implant-retained teeth (YES to question 32 or question 33):

34. Were you dissatisfied with your lower denture/implant-retained teeth? **

35. Did your lower denture/implant-retained teeth cause soreness or ulceration of the gum? ***

36. Did you find food particles collecting under your lower denture/implant-retained teeth? ***

37. Did you take out your lower denture/implant-retained teeth for eating? **

38. Did you feel insecure with your lower denture/implant-retained teeth? **

39. Were you worried that your lower denture/implant-retained teeth might fall out? *


n=18-21 n=6-9

Table II. Remaining LORQ items referring to prostheses and patient satisfaction with prosthe-ses. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Mean score and % of patients who said “often” or “always”




239March 2008

Table III. OHIP-14 instrument. Each item was scored as 1 = never, 2 = hardly ever, 3 = occasionally, 4 = fairly often, 5 = very often. Table gives mean score and % of patients who said “fairly often” or “very often”

Functional limitation

1. Have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures?

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

Physical pain 3. Have you had painful aching in your mouth? 4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures? **

Psychological discomfort 5. Have you been self-conscious because of your teeth, mouth or dentures? 6. Have you felt tense because of problems with your teeth, mouth or dentures? *

Physical disability

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?* 8. Have you had to interrupt meals because of problems with your teeth, mouth or dentures? *

Psychological disability

9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures? *

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

Social disability

11. Have you been a bit irritable with other people because of problems with your teeth, mouth or dentures?

12. Have you had difficulty doing your usual jobs because of problems with your teeth, mouth and dentures?

Handicap

13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth and dentures?

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

3.1

2.9

3.1

4.1

3.9

3.6

3.4

3.4

3.5

3.5

2.9

2.0

3.5

2.1

43

37

39

71

63

60

51

48

55

52

38

15

55

14

CDn=41-43


2.6

3.0

3.0

4.4

3.9

3.9

3.5

3.6

3.3

3.8

2.7

2.1

3.7

1.8

18

46

37

79

64

64

50

52

48

59

28

18

55

14

COMBn=30

2.7

2.3

2.5

3.5

3.3

3.0

2.7

2.8

2.7

3.4

2.3

2.0

3.0

1.8

27

23

19

50

50

46

35

23

31

42

23

20

31

12

PDn=27-29


Table IV. First 17 LORQ items: prosthodontics, oral rehabilitation, and routine general dental practice pa-tients. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Table provides mean score and % of patients who said “often” or “always”

1. Did you experience difficulty with chewing? ***


3. Did you experience difficulty with swallowing solids?


5. Did food particles collect under your tongue?

6. Did food particles stick to your palate? **

7. Did food particles stick inside your cheeks?


9. Did you have problems with drooling? *






15. Did your chewing ability affect your social life?

16. Did your chewing ability influence your choice of foods? *


3.0

2.3

1.7

1.2

1.8

2.9

1.9

2.1

1.6

1.9

1.9

2.0

1.8

2.2

2.5

3.0

1.6

63

33

18

4

18

62

21

27

11

23

28

32

24

38

49

67

13

Prosthodontic Studyn=96-104mean % mean % mean %

2.4

1.6

1.9

1.3

1.8

2.5

2.0

2.3

2.0

1.9

2.0

2.1

2.0

2.0

2.2

2.6

1.7

42

11

21

6

22

42

24

37

28

25

27

31

28

28

38

48

19

Oral Rehabilitation Study

General DentalPractice Study

n=81-89

1.3

1.3

1.1

1.1

1.2

1.3

1.2

1.4

1.1

1.1

1.2

1.1

1.1

1.5

1.2

1.3

1.1

5

3

2

1

2

3

3

9

3

1

2

1

1

10

2

4

2

n=344-345

Kruskal-Wallis test for difference between 3 groups was P<.001 for all itemsMann-Whitney test for differences between Prosthodontic and Oral Rehabilitation groups: ***P<.001, **.001<P<.01, *.01<P<.05

the maxillary prostheses. Between the OHIP-14 and the first 17 items in the LORQ, the median correlation was 0.39, with an IQR of 0.29 to 0.48. When considering the strongest cor-relations of 0.50 and above, all OHIP-14 items correlated with at least 1 of the first 17 LORQ items. The converse was not true, and various LORQv3 items did not have such strong cor-relations within the OHIP-14. LORQ items 4, 5, 7, 8, 9, and 14 were like this, and items 4 and 8 in particular, these having to do with the difficulty

of swallowing liquids and of mouth dryness.

Overall, 33% (34/102) of patients were somewhat or extremely de-pressed, 25% (26/102) were anxious or very anxious, and 15% (15/102) were both. Problems with mood and anxiety were slightly worse in patient group CD with complete maxillary and mandibular dentures (Mood: 40% (CD) versus 30% (COMB) versus 27% (PD); Anxiety: 33% (CD) versus 20% (COMB) versus 19% (PD)), but there were no significant differences

between the 3 groups. Reference data for mood and anxiety were only avail-able from the study of patients hav-ing routine appointments with gen-eral dentists. Of these patients, 7% (25/349) were somewhat or extreme-ly depressed, 10% (36/349) were anx-ious or very anxious, and 5% (19/349) were both.

Within a follow-up window of 14 ±3 days, there were data for 60 pa-tients. For the 33 LORQ items, me-dian kappa was 0.61, interquartile range was 0.54 to 0.66, and range




239March 2008

Table III. OHIP-14 instrument. Each item was scored as 1 = never, 2 = hardly ever, 3 = occasionally, 4 = fairly often, 5 = very often. Table gives mean score and % of patients who said “fairly often” or “very often”



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

Physical pain 3. Have you had painful aching in your mouth? 4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures? **

Psychological discomfort 5. Have you been self-conscious because of your teeth, mouth or dentures? 6. Have you felt tense because of problems with your teeth, mouth or dentures? *

Physical disability

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?* 8. Have you had to interrupt meals because of problems with your teeth, mouth or dentures? *

Psychological disability

9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures? *

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

Social disability



Handicap

13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth and dentures?


3.1

2.9

3.1

4.1

3.9

3.6

3.4

3.4

3.5

3.5

2.9

2.0

3.5

2.1

43

37

39

71

63

60

51

48

55

52

38

15

55

14

CDn=41-43


2.6

3.0

3.0

4.4

3.9

3.9

3.5

3.6

3.3

3.8

2.7

2.1

3.7

1.8

18

46

37

79

64

64

50

52

48

59

28

18

55

14

COMBn=30

2.7

2.3

2.5

3.5

3.3

3.0

2.7

2.8

2.7

3.4

2.3

2.0

3.0

1.8

27

23

19

50

50

46

35

23

31

42

23

20

31

12

PDn=27-29


Table IV. First 17 LORQ items: prosthodontics, oral rehabilitation, and routine general dental practice pa-tients. Each item was scored as 1 = never, 2 = sometimes, 3 = often, 4 = always. Table provides mean score and % of patients who said “often” or “always”

1. Did you experience difficulty with chewing? ***


3. Did you experience difficulty with swallowing solids?


5. Did food particles collect under your tongue?

6. Did food particles stick to your palate? **

7. Did food particles stick inside your cheeks?


9. Did you have problems with drooling? *






15. Did your chewing ability affect your social life?

16. Did your chewing ability influence your choice of foods? *


3.0

2.3

1.7

1.2

1.8

2.9

1.9

2.1

1.6

1.9

1.9

2.0

1.8

2.2

2.5

3.0

1.6

63

33

18

4

18

62

21

27

11

23

28

32

24

38

49

67

13

Prosthodontic Studyn=96-104mean % mean % mean %

2.4

1.6

1.9

1.3

1.8

2.5

2.0

2.3

2.0

1.9

2.0

2.1

2.0

2.0

2.2

2.6

1.7

42

11

21

6

22

42

24

37

28

25

27

31

28

28

38

48

19

Oral Rehabilitation Study

General DentalPractice Study

n=81-89

1.3

1.3

1.1

1.1

1.2

1.3

1.2

1.4

1.1

1.1

1.2

1.1

1.1

1.5

1.2

1.3

1.1

5

3

2

1

2

3

3

9

3

1

2

1

1

10

2

4

2

n=344-345

Kruskal-Wallis test for difference between 3 groups was P<.001 for all itemsMann-Whitney test for differences between Prosthodontic and Oral Rehabilitation groups: ***P<.001, **.001<P<.01, *.01<P<.05

the maxillary prostheses. Between the OHIP-14 and the first 17 items in the LORQ, the median correlation was 0.39, with an IQR of 0.29 to 0.48. When considering the strongest cor-relations of 0.50 and above, all OHIP-14 items correlated with at least 1 of the first 17 LORQ items. The converse was not true, and various LORQv3 items did not have such strong cor-relations within the OHIP-14. LORQ items 4, 5, 7, 8, 9, and 14 were like this, and items 4 and 8 in particular, these having to do with the difficulty

of swallowing liquids and of mouth dryness.

Overall, 33% (34/102) of patients were somewhat or extremely de-pressed, 25% (26/102) were anxious or very anxious, and 15% (15/102) were both. Problems with mood and anxiety were slightly worse in patient group CD with complete maxillary and mandibular dentures (Mood: 40% (CD) versus 30% (COMB) versus 27% (PD); Anxiety: 33% (CD) versus 20% (COMB) versus 19% (PD)), but there were no significant differences

between the 3 groups. Reference data for mood and anxiety were only avail-able from the study of patients hav-ing routine appointments with gen-eral dentists. Of these patients, 7% (25/349) were somewhat or extreme-ly depressed, 10% (36/349) were anx-ious or very anxious, and 5% (19/349) were both.

Within a follow-up window of 14 ±3 days, there were data for 60 pa-tients. For the 33 LORQ items, me-dian kappa was 0.61, interquartile range was 0.54 to 0.66, and range




241March 2008

Table V. OHIP-14: Prosthodontic and oral rehabilitation study patients. Each item was scored as 1 = never, 2 = hardly ever, 3 = occasionally, 4 = fairly often, 5 = very often. Table gives mean score and % of patients who said “fairly often” or “very”



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

Physical pain 3. Have you had painful aching in your mouth?

4. Have you found it uncomfortable to eat any foods because ofproblems with your teeth, mouth or dentures? ***

Psychological discomfort

5. Have you been self-conscious because of your teeth, mouth or dentures? **

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

Physical disability

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures? **

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

Psychological disability 9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures? **

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

Social disability



Handicap

13. Have you felt that life in general was less satisfying because of problemswith your teeth, mouth and dentures? **


2.8

2.8

2.9

4.0

3.7

3.5

3.3

3.3

3.2

3.6

2.7

2.0

3.4

1.9

31

36

33

68

60

57

46

42

46

52

31

17

48

13

Prosthodontic Studyn=94-97

mean % mean %

2.7

2.4

2.7

3.3

3.0

2.8

2.6

2.5

2.5

3.1

2.4

1.8

2.8

1.6

26

20

31

47

36

31

31

22

21

40

20

8

30

5

Oral Rehabilitation Studyn=83-88

Mann-Whitney test for differences between Prosthodontic and Oral Rehabilitation groups: ***P<.001, **.001<P<.01, *.01<P<.05

was 0.46 to 0.84. Median kappa for the first 17 items was 0.60 and for the other items, 0.61. For the OHIP-14 items, the median kappa value was 0.69, the interquartile range was 0.63 to 0.73. Overall, 26% (27/104) pro-vided free-text comments, the general trend being to identify issues which were of concern to them and relevant to treatment expectations. Examples of comments included, “I would like a nice smile” and “I would like my den-tures to be of good quality and have a good feeling of not being loose.”

DISCUSSION

The results from this study sup-port rejection of the null hypotheses, as the LORQv3 identified differences between the 3 patients groups attend-ing for replacement dentures as well as differences between data from the cancer cohort and the reference data obtained from the prosthodontic and GDP cohorts. The main limitation of this study was its cross-sectional de-sign and, hence, the inability to meas-ure responsiveness over time.

As part of the validation of the LORQv3, a cross-sectional survey of patients attending the prosthodontics unit at the Liverpool University Den-tal Hospital (LUDH) was undertaken. This was a consecutive group of pa-tients wearing conventional complete and/or removable partial dentures, and the response rate (104/116) was high. In interpreting the results, the specialist nature of the clinics must be recognized. Most of these patients tended to have ill-fitting and loose dentures, with problems compound-ed by atrophic mandibular residual ridges. As with previous studies, 3, 4 it appeared that the LORQv3 was ac-ceptable to patients, with few items omitted. Item 17 (difficulty open-ing mouth) was the most frequently omitted item, probably as a result of its location at the top of page 2 of the LORQv3 questionnaire.

For analysis the cohort was split into 3 groups, as described previous-ly. The validated OHIP-14 served as

a comparative measure even though it does not assess exactly the same issues. Patients in groups CD and COMB perceived more masticatory difficulties on the LORQv3 than pa-tients in group PD. Although there are no items in the OHIP-14 directly assessing mastication, patients in groups CD and COMB reported more discomfort when eating, a less satis-factory diet, and having to interrupt meals because of difficulty with their teeth, mouth, or dentures. Groups CD and COMB scored worse on the LORQv3 for swallowing solids, food particles collecting under the tongue, and food particles sticking inside the cheek, and worse on the OHIP-14 in physical pain (uncomfortable to eat any foods), psychological discom-fort (tense because of problems with teeth, mouth, or dentures), physical disability (diet unsatisfactory and in-terruption of meals), and psychologi-cal disability (difficult to relax).

The section of the LORQv3 relat-ing to dentures and patient satisfac-tion showed that patients wearing complete dentures (groups CD and COMB) were more embarrassed about conversing because of their dentures (item 20) and were more likely to refuse dinner invitations (item 21). Overall, patients in groups COMB and PD scored worse for items 26 to 31, being less satisfied and ex-periencing more problems with their maxillary prostheses compared to complete denture wearers (group CD). For items 34 to 39, groups CD and COMB generally scored worse regarding their mandibular den-tures than patients wearing partial dentures. Surprisingly, only 2 other studies compared patients wearing removable partial and complete den-tures. One study compared denture satisfaction in complete denture (CD) wearers with removable partial den-ture wearers (RPD). CD wearers were more satisfied with speech, mastica-tion, and retention of maxillary den-ture, while RPD wearers were more satisfied with retention and comfort of wearing mandibular dentures.10

The second study was a longitudinal clinical trial assessing the impact of implant-retained dentures on pa-tients’ perceived outcome using the OHIP-49 and a denture satisfaction questionnaire. Baseline satisfaction with maxillary dentures was higher than for mandibular dentures in eden-tulous patients.11

To help validate the LORQv3, this prosthodontic cohort was compared with oral rehabilitation and general dental practice patient groups. Pa-tients routinely seeing their general dentist reported the fewest prob-lems for all of the first 17 items of the LORQv3. Relative to patients in an oral rehabilitation clinic setting, however, the patients in this study had more difficulty with mastica-tion, pain on mastication, and food particles sticking under the palate (Table IV). The patients also report-ed more problems on the OHIP-14 in regard to physical pain, physical disability, psychological discomfort, and psychological disability (Table V). The problems experienced by the prosthetic group probably reflect the challenging nature of their prosthetic rehabilitation and, also, their expecta-tions relative to reality. The oncology patients may have been more accept-ing of their oral status given the other significant survival and QOL issues with which they had to cope. Also, it was noted that this group was in a low mood and anxious, and this, in turn, may have influenced their scor-ing of the LORQv3 more so than the comparative patient cohorts. There is evidence that negative mood can adversely impact the HRQOL.11 The 2-week test-retest reliability assess-ments were encouraging. One quarter of patients in this cohort made free-text comments, and no new items relevant to oral rehabilitation were identified, thus, further validating the content validity of the LORQv3.

CONCLUSIONS

The denture section of the LORQv3 identified expected differences among




241March 2008

Table V. OHIP-14: Prosthodontic and oral rehabilitation study patients. Each item was scored as 1 = never, 2 = hardly ever, 3 = occasionally, 4 = fairly often, 5 = very often. Table gives mean score and % of patients who said “fairly often” or “very”



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

Physical pain 3. Have you had painful aching in your mouth?

4. Have you found it uncomfortable to eat any foods because ofproblems with your teeth, mouth or dentures? ***

Psychological discomfort

5. Have you been self-conscious because of your teeth, mouth or dentures? **

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

Physical disability

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures? **

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

Psychological disability 9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures? **

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

Social disability



Handicap

13. Have you felt that life in general was less satisfying because of problemswith your teeth, mouth and dentures? **


2.8

2.8

2.9

4.0

3.7

3.5

3.3

3.3

3.2

3.6

2.7

2.0

3.4

1.9

31

36

33

68

60

57

46

42

46

52

31

17

48

13

Prosthodontic Studyn=94-97

mean % mean %

2.7

2.4

2.7

3.3

3.0

2.8

2.6

2.5

2.5

3.1

2.4

1.8

2.8

1.6

26

20

31

47

36

31

31

22

21

40

20

8

30

5

Oral Rehabilitation Studyn=83-88

Mann-Whitney test for differences between Prosthodontic and Oral Rehabilitation groups: ***P<.001, **.001<P<.01, *.01<P<.05

was 0.46 to 0.84. Median kappa for the first 17 items was 0.60 and for the other items, 0.61. For the OHIP-14 items, the median kappa value was 0.69, the interquartile range was 0.63 to 0.73. Overall, 26% (27/104) pro-vided free-text comments, the general trend being to identify issues which were of concern to them and relevant to treatment expectations. Examples of comments included, “I would like a nice smile” and “I would like my den-tures to be of good quality and have a good feeling of not being loose.”

DISCUSSION

The results from this study sup-port rejection of the null hypotheses, as the LORQv3 identified differences between the 3 patients groups attend-ing for replacement dentures as well as differences between data from the cancer cohort and the reference data obtained from the prosthodontic and GDP cohorts. The main limitation of this study was its cross-sectional de-sign and, hence, the inability to meas-ure responsiveness over time.

As part of the validation of the LORQv3, a cross-sectional survey of patients attending the prosthodontics unit at the Liverpool University Den-tal Hospital (LUDH) was undertaken. This was a consecutive group of pa-tients wearing conventional complete and/or removable partial dentures, and the response rate (104/116) was high. In interpreting the results, the specialist nature of the clinics must be recognized. Most of these patients tended to have ill-fitting and loose dentures, with problems compound-ed by atrophic mandibular residual ridges. As with previous studies, 3, 4 it appeared that the LORQv3 was ac-ceptable to patients, with few items omitted. Item 17 (difficulty open-ing mouth) was the most frequently omitted item, probably as a result of its location at the top of page 2 of the LORQv3 questionnaire.

For analysis the cohort was split into 3 groups, as described previous-ly. The validated OHIP-14 served as

a comparative measure even though it does not assess exactly the same issues. Patients in groups CD and COMB perceived more masticatory difficulties on the LORQv3 than pa-tients in group PD. Although there are no items in the OHIP-14 directly assessing mastication, patients in groups CD and COMB reported more discomfort when eating, a less satis-factory diet, and having to interrupt meals because of difficulty with their teeth, mouth, or dentures. Groups CD and COMB scored worse on the LORQv3 for swallowing solids, food particles collecting under the tongue, and food particles sticking inside the cheek, and worse on the OHIP-14 in physical pain (uncomfortable to eat any foods), psychological discom-fort (tense because of problems with teeth, mouth, or dentures), physical disability (diet unsatisfactory and in-terruption of meals), and psychologi-cal disability (difficult to relax).

The section of the LORQv3 relat-ing to dentures and patient satisfac-tion showed that patients wearing complete dentures (groups CD and COMB) were more embarrassed about conversing because of their dentures (item 20) and were more likely to refuse dinner invitations (item 21). Overall, patients in groups COMB and PD scored worse for items 26 to 31, being less satisfied and ex-periencing more problems with their maxillary prostheses compared to complete denture wearers (group CD). For items 34 to 39, groups CD and COMB generally scored worse regarding their mandibular den-tures than patients wearing partial dentures. Surprisingly, only 2 other studies compared patients wearing removable partial and complete den-tures. One study compared denture satisfaction in complete denture (CD) wearers with removable partial den-ture wearers (RPD). CD wearers were more satisfied with speech, mastica-tion, and retention of maxillary den-ture, while RPD wearers were more satisfied with retention and comfort of wearing mandibular dentures.10

The second study was a longitudinal clinical trial assessing the impact of implant-retained dentures on pa-tients’ perceived outcome using the OHIP-49 and a denture satisfaction questionnaire. Baseline satisfaction with maxillary dentures was higher than for mandibular dentures in eden-tulous patients.11

To help validate the LORQv3, this prosthodontic cohort was compared with oral rehabilitation and general dental practice patient groups. Pa-tients routinely seeing their general dentist reported the fewest prob-lems for all of the first 17 items of the LORQv3. Relative to patients in an oral rehabilitation clinic setting, however, the patients in this study had more difficulty with mastica-tion, pain on mastication, and food particles sticking under the palate (Table IV). The patients also report-ed more problems on the OHIP-14 in regard to physical pain, physical disability, psychological discomfort, and psychological disability (Table V). The problems experienced by the prosthetic group probably reflect the challenging nature of their prosthetic rehabilitation and, also, their expecta-tions relative to reality. The oncology patients may have been more accept-ing of their oral status given the other significant survival and QOL issues with which they had to cope. Also, it was noted that this group was in a low mood and anxious, and this, in turn, may have influenced their scor-ing of the LORQv3 more so than the comparative patient cohorts. There is evidence that negative mood can adversely impact the HRQOL.11 The 2-week test-retest reliability assess-ments were encouraging. One quarter of patients in this cohort made free-text comments, and no new items relevant to oral rehabilitation were identified, thus, further validating the content validity of the LORQv3.

CONCLUSIONS

The denture section of the LORQv3 identified expected differences among




various patient subgroups in this co-hort, confirmed by similar findings in the OHIP-14 and the literature. Thus, this part of the LORQv3 referring to dentures and patient satisfaction demonstrated good construct and criterion validity.

REFERENCES

1. List MA, Stracks J, Colangelo L, Butler P, Ganzenko N, Lundy D, et al. How do head and neck cancer patients prioritize treat-ment outcomes before initiating treatment? J Clin Oncol 2000;18:877-84.

2. Rogers SN, Gwanne S, Lowe D, Humphris G, Yueh B, Weymuller EA Jr. The addition of mood and anxiety domains to the Uni-versity of Washington quality of life scale. Head Neck 2002;24:521-9.

3. Pace-Balzan A, Cawood JI, Howell R, Lowe D, Rogers SN. The Liverpool Oral Rehabili-

tation Questionnaire: a pilot study. J Oral Rehabil 2004;31:609-17.

4. Pace-Balzan A, Cawood JI, Howell R, Butterworth CJ, Lowe D, Rogers SN. The further development and validation of the Liverpool Oral Rehabilitation Question-naire: a cross-sectional survey of patients attending for oral rehabilitation and gen-eral dental practice. Int J Oral Maxillofac Surg 2006;35:72-8.

5. Slade GD. Derivation and validation of a short-form oral health impact profile. Com-munity Dent Oral Epidemiol 1997;25:284-90.

6. Chamberlain BB, Chamberlain KR. Depres-sion: a psychologic consideration in com-plete denture prosthodontics. J Prosthet Dent 1985;53:673-5.

7. Friedman N, Landesman HM, Wexler M. The influences of fear, anxiety, and depres-sion on the patient’s adaptive responses to complete dentures. Part II. J Prosthet Dent 1988;59:45-8.

8. Brennan DS, Spencer AJ. Disability weights for the burden of oral disease in South Australia. Popul Health Metr 2004;2:7.

9. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Pro-file. Community Dent Health 1994;11:3-11.

10.Celebic A, Knezovic-Zlataric D. A com-parison of patient’s satisfaction between complete and partial removable denture wearers. J Dent 2003;31:445-51.

11.Allen PF, McMillan AS. A longitudinal study of quality of life outcomes in older adults requesting implant prostheses and complete removable dentures. Clin Oral Implants Res 2003;14:173-9.

Corresponding author:Prof. Simon RogersRegional Maxillofacial UnitUniversity Hospital AintreeFazakerley, Liverpool, L9 IALUKFax: 0151-529-5288E-mail: [email protected]

Copyright © 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.

Pace-Balzan et al

Customizing palatal contours of a denture to improve speech intelligibility

Hyung-Jun Kong, DDS,a and Carl A. Hansen, DDSb

Southern Illinois University, Alton, Ill

aAssistant Professor, Department of Restorative Dentistry.bRetired, Former Director, Graduate Prosthodontic Program, University of Florida.

Accurate approximation of palatal contours of a maxillary complete denture to a patient’s tongue can improve speech intelligibility, if other factors such as tooth position, occlusal plane, and occlusal vertical dimension are satisfactory. Customizing palatal contours of a maxillary complete denture can be accomplished by using tissue-conditioning material, which provides sufficient working time for a patient to pronounce a series of sibilant sounds while recording dynamic impression of the tongue. This article describes a technique for customizing palatal contours of a maxillary complete denture with autopolymerizing acrylic resin to improve speech intelligibility. (J Prosthet Dent 2008;99:243-248)

During denture fabrication, pho-netic evaluation is frequently neglect-ed,1,2 while more emphasis is placed on other key elements of successful denture treatment such as esthetics, function, and comfort.3 It is generally assumed that patients will success-fully adapt to new dentures within a few weeks.4-6 It may take longer to compensate for changes in palatal contours of maxillary complete den-tures, especially for elderly patients.5 Unfortunately, some patients never acclimate to the new dentures and continue to experience difficulties in pronouncing intelligible sounds, es-pecially the sibilant sounds.1,2,7,8 How-ever, by customizing palatal contours of a maxillary denture to the tongue, the patient may easily adapt to the de-finitive denture contour, which in turn shortens or eliminates the adjustment period for the achievement of proper enunciation.7

The physiologic /s/ sound is formed by adaptation of the lateral margins of the tongue to the palatal alveo-lar process of the posterior maxillae, channeling a stream of air through the medial groove on the dorsum of the tongue behind the maxillary central incisors.1,2,8 Tanaka6 reported that a reverse curve exists in the sagittal and

frontal sections of the palate in den-tate patients. This convexity is impor-tant for pronunciation of the sibilant sounds such as /s/ and /sh/.4,6 If the anterior palatal area is overcontoured such that the air stream is excessively impeded, an /s/ sound may be heard as a central or frontal lisp.2,9 How-ever, if this area is undercontoured, resulting in an insufficient impeding of the air stream, an /s/ sound may be perceived as a whistle.2,9 Therefore, defective sibilant articulations may be attributed to faulty palatal contours of complete dentures.

Optimal phonetics can be best achieved by obtaining a proper occlu-sal vertical dimension (OVD) and oc-clusal plane, correctly positioning the anterior and posterior teeth according to the esthetic and functional require-ments of the patient, and adequately contouring the palatal surface. Once teeth are correctly positioned at the correct OVD and on a proper occlusal plane, the waxed palatal contour of a maxillary complete denture should be evaluated for speech intelligibility be-cause incorrect tooth positions may also cause sibilant distortions5 (Fig. 1).

A palatogram is a simple and use-ful diagnostic tool for phonetic evalu-

ation of a maxillary complete denture patient, and functions by representing a static record of contact area between the palate and the tongue upon pro-nunciation of sounds.1,2,10 Although the contact areas for certain sounds are individually determined, there ex-ist sufficient similarities to constitute a pattern, which serves as a reference (Fig. 2). By altering the palatal con-tour of the maxillary denture for a patient who has sibilant distortions, improved intelligibility of the sounds and/or a reduced period of adapta-tion can be achieved. This article de-scribes a technique for customizing the palatal contour of a maxillary complete denture with autopolymer-izing acrylic resin to improve the intel-ligibility of speech.

TECHNIQUE

1. Verify the tooth arrangement, OVD, and the occlusal plane of a trial denture or a processed denture.

2. Spray green-colored indicating material (Occlude; Pascal Co Inc, Belle- vue, Wash) on the palatal surface as a contact-recording media.1

3. Insert the denture and have the patient say “so-so” and open wide2 (Fig. 3). Note that the /o/ sound pro-

Kong and Hansen

Documents

The further development and validation of the Liverpool Oral Rehabilitation Questionnaire (LORQ) version 3: A cross-sectional survey of patients referred to a dental hospital for removable