Abstract
Quality of life outcomes among patients receiving implants have been well studied, but little is known about the effects of bone augmentation in this therapy. The purpose of this paper was to assess quality of life changes among postmenopausal women receiving dental implants with bone augmentation during implant therapy. This was a prospective cohort study. 48 patients were recruited at the University of Connecticut Health Center and received one of three surgical augmentation methods: dehiscence repair; expansion alone; or expansion with dehiscence repair. The predictor variable was type of augmentation procedure. Quality of life measured by the Oral Health Impact Profile-14 (OHIP-14) was the outcome measure and was assessed prior to treatment, 1 week, 8 weeks and 9 months after surgery. Changes in OHIP-14 were evaluated by repeated measures analysis of variance. The mean initial OHIP-14 scores on total items checked were 4.6 (SD = 3.0) and declined significantly to 2.0 (SD = 2.0) at 9 months. The mean baseline severity score was 15.4 (SD = 8.9) improving significantly to 7.5 (SD = 7.6) at 9 months. Type of augmentation procedure did not affect quality of life. The participants’ quality of life improved continuously from the pretreatment to the 9-month assessment, including improvements 1 week after implant placement.
A literature review of patient-based outcomes in dental implant research conducted in 1998 illustrates the relative paucity of data on patient perceptions of implant therapy with only 19 studies published at that time. Locker’s assessment of the literature (1998) indicates that the studies suffer from weak designs and are limited by using unvalidated measures of patient satisfaction. Quality of life impacts are not systematically assessed. A more recent review indicates that the literature on patient satisfaction with dental implants is expanding, but the quality of the studies remains generally poor. Some studies use their own questions that assess chewing ability, self-image and esthetics or use adaptations of generic measures of health related quality of life . Other studies employ standardized and validated measures to assess oral health related quality of life, including the Oral Health Impact Profile and Groningen Activity Restriction Scale – Dentistry . Results from these studies are mixed with some reporting significant improvement in quality of life among patients receiving implant therapy while other studies do not find any differences between those receiving implant supported prostheses and those receiving conventional dentures .
The literature on quality of life or patient-based outcomes in dental implant research assesses the effects of implant-supported overdentures with or without a comparison to patients receiving conventional dentures. Relatively few studies investigate quality of life outcomes among patients receiving single-tooth replacements. Gibbard and Zarb report the results of a 5-year follow-up of patients receiving one or more single tooth implants; 30 of 49 (61%) patients originally included in the study completed the follow-up survey. Five items assess patient satisfaction with appearance, functioning, cleaning ease, willingness to undergo another implant procedure and willingness to recommend implant therapy. Responses range from extremely dissatisfied (score = 1) to extremely satisfied (score = 5). Total scores could range from 5 to 25; respondents were very satisfied with outcomes of therapy with a mean score of 23 (SD = 1.44).
A study conducted in Germany with the German version of Oral Health Impact Profile (OHIP-G 21) compares oral health related quality of life among dentate ( n = 124) and partially edentulous patients ( n = 219) and evaluates changes in quality of life after implant therapy . Partially edentulous patients report significantly worse quality of life prior to treatment compared to the fully dentate group with mean scores on the OHIP-21 of 17.1 and 3.4, respectively. The most common problems are chewing function, worry and dissatisfaction with appearance. Post-treatment scores on the OHIP-21 improve significantly to a mean of 5.4, close to the scores of the dentate group.
A recent multi-center trial of single implant placements evaluates the outcomes of implants placed immediately after extractions compared to placement in healed alveolar ridges. The 14-item Oral Health Impact Profile (OHIP-14) is used to assess quality of life outcomes. OHIP-14 is calculated such that higher scores indicate better quality of life. 96 patients received 102 implants and completed the OHIP-14 at four time points: prior to treatment, 1, 6 and 12 months post-treatment. OHIP-14 scores improves significantly over time; mean scores on items are 4.5 at baseline, 4.7 at 1 month, 4.8 at 6 months and 4.8 at 12 months. There are no differences between patients treated immediately post extraction compared to those placed after healing.
Studies of single-tooth implants indicate that oral health related quality of life improves after therapy, but none of these studies addresses the effect of bone augmentation on perceived quality of life. The purpose of this study is to evaluate oral health related quality of life among post-menopausal women prior to implant placement with simultaneous bone augmentation and to assess changes in quality of life during and post treatment. The authors hypothesize that quality of life will decline post surgery when patients may experience discomfort but will improve at 8 weeks and 9 months as the implant heals and the restoration is completed. The authors also hypothesize that more invasive bone augmentation treatment, combined expansion/deshiscence, will have more negative impacts on quality of life compared to less invasive methods, such as singular expansion or dehiscence repair. The specific aim of the study was to compare outcomes associated with type of bone augmentation.
Materials and methods
This was a prospective cohort study, structured as a ‘best clinical practice’ study. The research team chose the grafting technique according to clinical assessments and radiographic data.
The three surgical augmentation methods were used as follows: dehiscence repair combined with implant placement (slightly deficient alveolar ridges); expansion combined with implant placement (moderately deficient alveolar ridge width); or expansion in conjunction with dehiscence repair combined with implant placement. Ridge width assessment and consequent choice of surgical method were made as a research team utilizing clinical assessments, clinical photographs, panoramic and periapical radiographs and three-dimensional radiographic dicom images acquired using cone beam computed tomography (CBCT) (CB MercuRay, Hitachi Corp, Japan) obtained at the screening/baseline examinations.
Alveolar bone morphology in the edentulous area was confirmed visually at the time of surgical entry. Dental treatment included bone augmentation, simultaneous implant placement and implant restoration procedures. For all subjects, treatment included the surgical placement of roughened titanium (Ti) solid screw implants (3.3 mm, 4.1 mm or 4.8 mm diameter). Prosthetic procedures (including placing load and torque through abutment placement) were started 8–10 weeks after surgical implant placement; three participants received provisional replacements prior to final restorations. Prosthetic reconstruction consisted of either single crown or (up to three unit) multiple unit fixed prosthesis placement. Questionnaires were administered by trained research staff at baseline (prior to treatment), 1 week, 8 weeks and 9 months post implant placement. Questionnaire instructions were reviewed at each time point.
The study was approved by the University of Connecticut Health Center’s Institutional Review Board. Patients were recruited at the University of Connecticut Health Center through newspaper, newsletter, internet, broadcast messages at the Health Center and radio advertisements as well as through the Osteoporosis Center and Dental Implant Center. To be eligible, patients had to: be female; aged 55–80 years; have at least 12 remaining teeth; and one intra-oral edentulous area with a narrow alveolar ridge. Patients were excluded if they: had been diagnosed with bone metastasis, Paget’s disease, or hyperparathyroidism; were undergoing long-term corticosteroid therapy; or were receiving parathyroid hormone treatment. 48 patients have completed the 9 month assessment.
The predictor variable was the type of bone augmentation: dehiscence repair combined with implant placement; or expansion combined with implant placement; or expansion in conjunction with dehiscence repair combined with implant placement.
The main outcome variable was oral health related quality of life which was measured by the Oral Health Impact Profile-14 . It consisted of 14 items and assessed the frequency of problems with pain, eating, speaking, self esteem, functional status and psychological well-being. The response set was a 5 point scale from ‘Very often’ (score of 5) to ‘Never’ (score of 1). Two scoring methods were used: total items checked, a count of the number of items when the participant responded ‘Very often, fairly often and occasionally’; severity, the sum of the total score, ranging from 14 to 70. This scale has been used in previous studies of implant therapy and has well-established validity and reliability . The items are listed in Table 1 although it should be noted that item 7 is slightly different from the original OHIP which stated unsatisfactory rather than satisfactory. Internal reliability was very high with Cronbah’s alpha at 0.860 at the baseline measure, 0.872 at week 1 and 0.84 at week 8 and 0.877 at 9 months. This item had no effect on internal reliability.
| 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? |
| 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? |
| 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? |
| 7. Has your diet been satisfactory because of your teeth, mouth or dentures? |
| 8. Have you had to interrupt meals because of your teeth, mouth or dentures? |
| 9. Have you found it difficult to relax because of your teeth, mouth or dentures? |
| 10. Have you been a bit embarrassed because of your teeth, mouth or dentures? |
| 11. Have you been a bit irritable because of your teeth, mouth or dentures? |
| 12. Have you had difficulty doing your usual jobs because of your teeth, mouth or dentures? |
| 13. Have you felt that life in general was less satisfying because of your teeth, mouth or dentures? |
| 14. Have you been totally unable to function because of your teeth, mouth or dentures? |
Data were collected on age in years, marital status (married, divorced, widowed and single/never married), education (high school or less; some college and college education or more), employment status, race (White, African American, Asian, Native American, Pacific Islander, other) and family income (<$20,000, $20–29,999, $30–39,999, $49–49,999, $50–74,999, $75–99,999, >$100,000). Owing to the small numbers in some categories, marital status was dichotomized as married/not married; race was also dichotomized as white/other; and family income was grouped into four categories: $<30,000, $30–74,999, $75–99,999, and ≥$100,000
Data analysis
The analysis began with the description of the sample, including the distribution of demographic characteristics, type of bone augmentation and OHIP scores. This was followed by analysis of the bivariate relationships between demographic characteristics, type of bone augmentation and OHIP scores. Repeated measures analysis of variance assessed trends over time in OHIP and the effects of type of bone augmentation on OHIP over time adjusting for demographic characteristics.
Results
Table 2 presents the descriptive characteristics of the sample. The mean age was 61.9 years (SD = 5.5), the majority were married (52.1%), had a college education (56.3%), were white (85.4%), employed (62.5%) and had family incomes between $30,000 and $99,999 (53.5%). Half of the sample received a combined expansion with the dehiscence procedure, 22% received dehiscence only and 27.1% received expansion only. There were no significant differences in the demographic characteristics by type of grafting technique assuring that these factors were equally distributed among the surgical groups.
| Variable | Mean (SD) | Percent ( n = 48) |
|---|---|---|
| Age | ||
| Mean (SD) | 61.9 (5.5) | |
| 55–59 | 44.7 | |
| 60–64 | 25.5 | |
| 65+ | 29.8 | |
| Marital status | ||
| Married | 46.9 | |
| Not married | 52.1 | |
| Education | ||
| High school | 16.7 | |
| Some college | 27.1 | |
| College + | 56.3 | |
| Race | ||
| White | 85.4 | |
| Other | 14.6 | |
| Employment status | ||
| Employed | 62.5 | |
| Not employed | 37.5 | |
| Family income | ||
| $<30,000 | 23.3 | |
| $30–74,999 | 32.6 | |
| $75–99,999 | 20.9 | |
| $≥100,000 | 23.3 | |
| Procedure type | ||
| Dehiscence | 22.9 | |
| Expansion | 27.1 | |
| Expansion with dehiscence | 50.0 | |
| Unadjusted OHIP scores | ||
| Pretreatment | ||
| Total checked | 4.6 (3.0) | |
| Severity | 15.4 (8.9) | |
| 1 week | ||
| Total checked | 4.5 (3.2) | |
| Severity | 13.7 (8.2) | |
| 8 weeks | ||
| Total checked | 3.1 (2.7) | |
| Severity | 10.6 (7.5) | |
| 9 months | ||
| Total checked | 2.0 (2.5) | |
| Severity | 7.5 (6.6) | |
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