Journal of Dentistry

Journal of Dentistry 29 (2001) 243246 www.elsevier.com/locate/jdent

Can dentures improve the quality of life of those who have experienced considerable tooth loss?
Colman McGrath a,*, Raman Bedi b
b

Periodontology and Public Health, Faculty of Dentistry, Prince Philip Dental Hospital, University of Hong Kong, Hospital Road, Hong Kong WHO Collaborating Centre for Disability, Culture and Oral Health. National Centre for Transcultural Oral Health, Eastman Dental Institute for Oral Health Care Sciences, University College London, London, UK Received 5 May 2000; revised 17 October 2000; accepted 7 November 2000

Abstract Objectives: The aim of this study was to identify variations in the impact of oral health on quality of life (OHQOL) among UK residents in relation to self-reported number of teeth possessed and denture status. In addition, to determine whether recourse to a removable prosthesis for those who claimed that they had experienced considerable tooth loss (having ,20 teeth) was associated with quality of life. Methods: The vehicle for this was the Ofce for National Statistics Omnibus survey in Great Britain. A random probability sample of 2667 addresses was selected in a multistage sampling process. Participants were interviewed about their oral health status. The impact of oral health on quality of life was measured utilising the OHQoL-UK(W) q measure. Results: The response rate was 68%. Variations in OHQoL-UK(W) q scores were apparent in relation to self-reported number of teeth possessed (P , 0.001) and denture status (P , 0.001). Moreover, disparities in OHQOL were apparent among those who experienced considerable tooth loss who didn't have recourse to a denture (P , 0.001). In regression analysis, those who claimed that they had ,20 natural teeth but had no recourse to a denture were less than half as likely to enjoy enhanced oral health related quality of life compared to others in the population (OR 0.46, 95% CI 0.30, 0.71), controlling for socio-demographic factors. Conclusions: Experience of considerable tooth loss without recourse to a removable dental prosthesis is an important predictor of oral health related quality of life, as captured by OHQoL-UK(W) q, and associated with reduced quality of life. q 2001 Elsevier Science Ltd. All rights reserved.
Keywords: Quality of life; Dentures; Outcome measures; Oral rehabilitation

1. Introduction Systematic data on the consequences of tooth loss have been collected for some time now. Early interest focussed on the functional consequence of tooth loss, exploring association between tooth loss and chewing ability (self-assessment of masticatory ability) and masticatory efciency (`objective' laboratory tests) [1,2]. It is claimed that chewing ability is substantially reduced among edentulous compared to dentate persons but that it is particularly low in dentate individuals wearing partial dentures [3,4]. However, only minor differences in reported chewing ability between individuals with complete dental arches and those with shortened dental arches have been observed [5,6]. Consequently, there is wide spread agreement that missing teeth do not per se need prosthetic replacement
* Corresponding author. E-mail address: mcgrathc@hkucc.hku.hk (C. McGrath).

[7]. It has been suggested that ten occluding pairs of teeth or 20 well-distributed teeth (`shortened dental arch') are appropriate for optimal masticatory performance [8,9]. Moreover, there is conicting evidence of the benets of replacing missing teeth by removable prosthesis in terms of inuences on dietary intake or nutrition [1012]. More recently there has been a growing interest on the inuences of tooth loss on life quality, not only its physical, functional consequences but also its social and psychological inuences [13]. While studies, have on the whole only focused on the consequences on tooth loss among older people, there is widespread agreement that tooth loss is strongly associated with poor oral health related quality of life [14]. There is however a lack of national perspectives on the effects of tooth loss and denture status on life quality. Moreover, there is a need to investigate if removable prosthesis can improve the quality of life of those who experience considerable loss of teeth. The aims of this study were to identify variations in the

0300-5712/01/$ - see front matter q 2001 Elsevier Science Ltd. All rights reserved. PII: S 0300-571 2(00)00063-4

244 Table 1 Prole of the study group

C. McGrath, R. Bedi / Journal of Dentistry 29 (2001) 243246

Number (%) Socio-demographic prole Age group 1664-year-olds Aged 65 and older Gender Social class Male Female Higher (I, II, IIINM) Lower (IIIM, IV, V) Uncategorised 1384 (77) 417 (23) 813 (45) 988 (55) 999 (56) 737 (41) 65 (04) 1256 (70) 218 (12) 327 (18) 220 (12) 337 (19) 1244 (69) 1699 (94) 102 (06)

Self-reported oral health status Number of teeth 20 or more 1019 Less than 10 Denture status I wear full dentures I wear partial dentures I do not wear dentures More than 20 teeth/less than 20 teeth with recourse to a denture Less than 20 teeth without recourse to a denture

how oral health affects life quality [15]. The instrument's psychometric properties have been validated in a number of studies that have demonstrated its validity and reliability [16,17]. OHQoL-UK(W) q consists of 16 key questions relating to oral health related quality of life, respondents were rst asked what `effect' their oral health had on the these key areas and then asked to rate the `impact' of these effects on their overall quality of life. Summing up responses from individual questions can produces overall OHQoL-UK(W) q scores ranging from 16 to 144. Sixteen is equivalent to the lowest possible score, that is, oral health had a bad effect in all 16 areas. One hundred and forty-four is the maximum possible score and represents a good effect in all sixteen areas. 2.3. Data analysis The response rate to the survey was calculated and the prevalence of tooth loss and use of removable dental prosthesis, based on self-reported number of teeth possessed and denture status was explored. Variations in OHQoL-UK(W) q scores in relation to self-reported oral health status number of teeth possessed and denture status was investigated. Following on, disparities in oral health related quality of life between those who claimed they experienced considerable tooth loss (possessing less than 20 teeth) but did not have recourse to a removable dental prosthesis compared with the rest of the group was explored. The statistical tests chosen to identify variations in OHQoL-UK(W) q scores in relation to self reported oral health status were the MannWhitney U-test (for comparison between two independent groups) and Kruskal-Wallis test (for comparison between more than two groups). These non parametric alternatives to the t-test were chosen because the OHQoL-UK(W) q scale is an interval scale rather then a continuous one and thus the aim was to identify difference in the ranking of the test variable. Subsequently, the study group was categorized into two groups, those with `enhanced' and `reduced' oral health related quality of life and this binary variable was utilised as the dependent variable in the logistic regression analysis. The categorization into the two groups was based on national OHQoL-UK(W) q scores, with those having above the national median OHQoL-UK(W) q score belonging to the `enhanced' quality of life group. The combined effect of socio-demographic factors (age, gender and social class) and proxy oral health measure (recourse to a denture) on `enhanced' oral health related quality of life was explored in the logistic regression analysis (forward: wald). 3. Results The response rate to the survey was 68% with 1801 people throughout the UK participating in the study. Twenty-one per cent (558) declined to take part in the survey, 8% (224) of households could not be contacted during the study period

Recourse to a denture

impact of oral health on life quality in relation to selfreported number of teeth possessed and denture status in Britain. In addition, to identify disparities in oral health related quality of life between people who claimed they experienced considerable tooth loss (possessing less than 20 teeth) with and without recourse to a removable dental prosthesis. 2. Materials and methods 2.1. Study group The vehicle for this study was the Ofce for National Statistics Omnibus survey, undertaken in June 1999, in Great Britain. The sampling frame was the entire Postcode Address Filethe most complete list of addresses in Britain. One hundred postal sectors were selected from which 30 household addresses were randomly selected throughout the country, 2667 of which were eligible addresses, the others being unoccupied buildings. Trained interviewers sought to carry out a face-to-face interview with an adult respondent at each household address selected. 2.2. Data collection Participants were asked about their oral health status number of teeth they possessed and denture status. In addition, the impact of oral health on their quality of life was assessed utilising the OHQoL-UK(W) q measure, which was developed based on the public's perception in the UK of

C. McGrath, R. Bedi / Journal of Dentistry 29 (2001) 243246 Table 2 Variations in oral health related quality of life in relation to self-reported oral health status OHQoL-UK(W) q Mean (SD) Number of teeth Denture status 20 or more Less than 20 I wear full dentures I wear partial dentures I do not wear dentures More than 20 teeth or less than 20 teeth with recourse to a denture Less than 20 teeth without recourse to a denture I wear dentures I do not wear dentures 92 (17) 85 (14) P , 0.001 86 (13) 87 (15) 91 (17) P , 0.001 90 (17) 83 (14) P , 0.001 85 (13) 77 (12) P , 0.001

245

Recourse to a denture

When the combined effect of the socio-demographic factors (age group, gender and social class) and selfreported oral health status was explored in the regression analysis, Table 3. Recourse to a denture emerged as an important predictor of oral health related quality of life controlling for socio-demographic variables. Those who claimed they had experienced considerable tooth loss having less than 20 teethand who did not wear a denture were less than half as likely to enjoy enhanced oral heath related quality of life compared to those who had more than 20 teeth or had 20 teeth but had recourse to a denture. Among the socio-demographic variables younger people and those from higher social class background were more likely to enjoy enhanced oral health related quality of life compared to older people and those from lower social class backgrounds respectively. 4. Discussion This study represents one of rst national surveys of oral health related quality of life and its relationship to oral health rehabilitation. The relatively high response rate, the large number of participants and the random sampling process utilised, provides major strength to this research. Oral health status was based on self-reported number of teeth possessed and denture status rather than employing a clinical oral examination to gather such information. While some concerns maybe raised regarding the validity of such data, there is ample evidence to suggest that patients are adept in providing such information [18,19]. Moreover, ndings from the recent adult dental health survey in Britain has suggested a low level of edentulism among the population and that many are retaining 20 or more teeth as reported in this study [20]. Bivariate analysis identied variations in oral health related quality of life in relation to self reported oral health statusnumber of teeth possessed and denture status, variations which have widely been reported in the literature [14]. It is also interesting to note that large variations in OHQoLUK(W) q scores were particularly apparent among those who claimed they had less than ten teeth who did not have recourse to a denture compared with those with a similar number of teeth who wore a denture (P , 0.001).

Among those with ,10 teeth (n 327)

and 2% (84) of interviews were discarded because of incomplete quality of life sections. The majority of respondents claimed they had more than 20 teeth (70%, 1256). Thirtyone per cent (557) claimed that they wore either partial or full dentures. Six per cent (102) reported that they had less than 20 teeth but did not wear any removable dental prosthesis. The socio-demographic prole of the study groups and other self-reported oral health status information and is presented in Table 1. Bivariate analysis identied variations in OHQoLUK(W) q scores in relation to self reported number of teeth possessed (P , 0.001), denture status (P , 0.001), Table 2. Furthermore disparities in OHQoL-UK(W) q scores were apparent in relation to tooth loss and recourse to a dental prosthesis, those who claimed they had less than 20 teeth and did not have recourse to a denture had signicantly lower OHQoL-UK(W) q scores compared to those who had more than 20 teeth or who had less than 20 teeth but used a denture. Furthermore, among those who claimed that had less than 10 teeth (n 327) recourse to removable dental prosthetics was strongly associated with OHQoL-UK(W) q scores (P , 0.001).
Table 3 Findings from the logistic regression analysis Regression coefcient Enhanced OHQOL Recourse to denture (0 no, 1 yes) Age group (0 ,65, 1 65 1 ) Social class (0 lower, 1 higher) Gender (0 male, 1 female) 2 0.78 2 0.30 0.41

Standard error 0.22 0.12 0.10

Odds ratio 0.46 0.74 1.50

95% Condence interval 0.30, 0.71 0.59, 0.93 1.23, 1.83

P value , 0.001 , 0.01 , 0.001 0.08

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C. McGrath, R. Bedi / Journal of Dentistry 29 (2001) 243246 [3] Poyiadjis YM, Likeman PR. Some clinical investigations of the masticatory performance of complete denture wearers. Journal of Dentistry 1984;12:33441. [4] Lappalainen R, Nyyssonen V. Self-assessed chewing ability of Finnish adults with removable dentures. Gerodontics 1987;3:23841. [5] Aukes JN, Kayser AF, Felling AJ. The subjective experience of mastication in subjects with shortened dental arches. Journal of Oral Rehabilitation 1988;15:3214. [6] Witter DJ, Cramwinckel AB, van Rossum GM, Kayser AF. Shortened dental arches and masticatory ability. Journal of Dentistry 1990;18:1859. [7] Devlin H. Replacement of missing molar teetha prosthodontic dilemma. British Dental Journal 1994;176:3133. [8] Steele JG, Ayatollahi SM, Walls AW, Murray JJ. Clinical factors related to reported satisfaction with oral function amongst dentate older adults in England. Community Dentistry Oral Epidemiology 1997;25:1439. [9] Witter DJ, van Palenstein Helderman WH, Creugers NH, Kayser AF. The shortened dental arch concept and its implications for oral health care. Community Dentistry Oral Epidemiology 1999;27:24958. [10] Chauncey HH, Muench ME, Kapur KK, Wayler AH. The effect of the loss of teeth on diet and nutrition. International Dental Journal 1984;34:98104. [11] Krall E, Hayes C, Garcia RJ. How dentition status and masticatory function affect nutrient intake. American Dental Association 1998;129:12619. [12] Lamy M, Mojon P, Kalykakis G, Legrand R, Butz-Jorgensen E. Oral status and nutrition in the institutionalized elderly. Journal of Dentistry 1999;27:4438. [13] Locker D. Health outcomes of oral disorders. International Journal of Epidemiology 1995;24:S859. [14] Slade Ed. GD. Measuring Oral health related Quality of life. Chapel Hill: University of North Carolina, Dental Ecology, 1997. [15] McGrath C, Bedi R, Gilthorpe MS. Oral health related quality of lifeviews of the public in the United Kingdom. Community Dental Health 2000;17:37. [16] McGrath C, Bedi R, Bowling A. An evaluation of a measure of oral health related quality of lifeOHQoL-UK(W)q. Journal of Dental Research 1999;78:1051. [17] McGrath C, Adu-Ababiof F, Zaki AS, Bedi R. An evaluation of an oral health related quality of life measureOHQoL-UK (W)q in Ghana. Journal of Dental Research 1999;78:1059. [18] Axelsson G, Helgadottir S. Comparison of oral health data from selfadministered questionnaire and clinical examination. Community Dentistry Oral Epidemiology 1995;23:3658. [19] Unell L, Soderfeldt B, Halling A, Paulander J, Birkhed D. Oral disease, impairment, and illness: congruence between clinical and questionnaire ndings. Acta Odontology Scandanivian 1997;55:12732. [20] Kelly M, Steele J, Nuttall N, Bradnock G, Morris J, Nunn J,, Pine C, Pitts N, Treasure E, White D. Adult Dental Health Surveyoral health in the United Kingdom 1998. London: The Stationery Ofce, 1998. [21] McGrath C, Bedi R. The value and use of quality of life measures in the primary dental care setting. Primary Dental Care 1999;6:5357.

Moreover, ndings from the logistic regression analysis demonstrated that recourse to a denture for those who claimed that they has less than 20 teeth was a major determining factor of oral health related quality of life having controlled for known confounding factors age group, gender and social class. Those with less than 20 teeth who did not wear dentures were less than half as likely to enjoy enhanced oral health related quality of life compared to those with a similar number of teeth who had recourse to a denture or those with more than 20 teeth. This would suggest the importance and value of oral rehabilitation for people who have experienced considerable tooth loss. Furthermore it highlights the benets of oral health related quality of life measures such as OHQoL-UK(W) q, as important tools in assessing oral health outcomes. These tools may become increasing important in oral health rehabilitation in assessing patients needs, evaluating outcomes and prioritising care [21]. 5. Conclusion In conclusion, variations in the impact of oral health on life quality in relation to self-reported number of teeth possessed and denture status in Britain were observed. Those who claimed they experienced considerable tooth loss (possessing less than 20 teeth) but who did not have recourse to a denture were among those with the poorest oral health related quality of life in the population having controlled for socio-demographic factors. Acknowledgements OHQoL-UK(W) q is a copyrighted instrument of oral health related quality of life. Permission and details of its use may be obtained from the WHO collaborative centre for disability, culture and oral health, Eastman Dental Institute for Oral Health Care Sciences, University College London, London WC1X 8LD, UK. References
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