- Email: [email protected]
Attitudes of saudi male patients toward the replacement of teeth
Attitudes of Saudi male patients toward the replacement of teeth Riyadh Akeel, BDS, MDS, PhDa College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia Statement of problem. The objective of tooth replacement is the restoration of esthetics and function. Patient perceptions of esthetic and functional needs may not match the dental professional’s assessment of these needs. Purpose. The objective of this study was to investigate the relationship between patient perceptions and professional assessments of prosthetic treatment needs in a population limited to Saudi men. Material and methods. The study population comprised 238 Saudi Arabian men between the ages of 16 and 77. Subjects were classified in accordance with 3 parameters: age (16-25, 26-35, 36-45, or ⬎45 years); completed education (primary, high school, or higher education); and number of missing teeth (1, 2-3, 4-6, or ⬎6). A structured interview was conducted and each subject was asked 3 closed-ended (yes/no) questions on tooth loss and its effects. The interview was followed by a dental examination in which each subject’s dental status and normative treatment needs were assessed. Patient perception data were compared to professionally assessed need. Data were analyzed with McNemar’s test (␣⫽.05). Results. Overall, 82% (194) of subjects expressed the need to replace their missing teeth. Forty-four percent (105) believed that tooth loss negatively affected their appearance, and 63% (150) thought that tooth loss reduced their chewing efficiency. The discrepancy between perceived and professionally assessed need in regard to function was significant (P⬍.01). Conclusion. Within the limitations of this study, subjective perceptions of esthetic and functional treatment needs were highly variable among the Saudi male patients evaluated. Patient perceptions could not be predictably estimated by professionally assessed clinical need. (J Prosthet Dent 2003;90:571-7.)
CLINICAL IMPLICATIONS Within this limited survey of Saudi male patients, some patient concerns were not supported by professional assessments of esthetic and functional treatment needs.
.
D
entists tend to assess the clinical need for prosthetic treatment based on the existence and location of edentulous spaces in the dental arch.1,2 Bjorn and Owall1 noted that missing teeth are replaced primarily for social and esthetic reasons and that treatment decisions cannot be based solely on professional factors. Previous studies2-5 reported a discrepancy between the treatment needs perceived by patients and those assessed by dental professionals. The reasons for reduced patient demand for prosthetic treatment are numerous, but include the unavailability of dental services, patients’ financial status, and cultural habits.6-8 A growing recognition that more emphasis be placed on patient-mediated concerns in prosthetic treatment planning is apparent from the literature.9,10 Kayser11 suggested that the need to replace teeth, when it is based solely on the dentist’s presumptions of the impact that Presented at the International College of Prosthodontists meeting, in collaboraton with the 8th annual Convention of Lebanese University, Beriut, Lebanon, September 2000. a Chairman, Department of Prosthetic Dental Sciences. DECEMBER 2003
morphological shortfalls could have, may amount to overtreatment. He introduced the concept of the shortened dental arch, which has gained popularity in the last 2 decades.12-17 Consequently, more information has been published on realistic treatment needs8 and sociodental treatment needs of different populations.2,18,19 These concepts suggest that limited treatment may be acceptable for patients with no perceived need for tooth replacement. Patients who express subjective needs for prosthetic treatment may be a higher priority.10 Perceived needs for tooth replacement are based on esthetic, social, functional, and cultural factors.20-23 According to data gathered in previous reports, many patients find the 6 anterior teeth indispensable but will accept edentulous spaces in the posterior regions of the mouth.1,6,7,20-23 Several studies have reported that patients underestimate their treatment needs3,9,10,22 There is no published evidence, however, that patients overestimate treatment needs. The aims of this study were: (1) to document the perceived prosthetic treatment needs of a limited sample of Saudi male patients and the factors THE JOURNAL OF PROSTHETIC DENTISTRY 571
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Table I. Distribution of responses to 3 yes/no questions Questions
Yes: number (%)
Do you think you need to replace the missing tooth (teeth)?* Do you think losing your tooth (teeth) has affected your appearance? Do you think losing your tooth (teeth) has affected your ability to chew food?
No: number (%)
194 (82)
43 (18)
105 (44)
133 (56)
150 (63)
88 (37)
*One subject did not respond.
Table II. Distribution of responses to Question I according to number of missing teeth* No. of missing teeth
1 2–3 4–6 ⬎6
Need to replace: number (%)
Do not need to replace: number (%)
52 (74) 58 (76) 47 (89) 37 (97)
18 (26) 18 (24) 6 (11) 1 (3)
*One subject did not respond. Chi-square goodness of fit ⫽ 0.68 (NS).
that influenced their perceptions, and (2) to compare these perceived needs to professionally assessed clinical needs.
MATERIAL AND METHODS The study population comprised 238 male subjects selected from the screening clinic of the King Saud University College of Dentistry. To be included in the study, subjects had to be men between the ages of 16 and 77 and have at least 1 missing tooth (excluding third molars) that had not been replaced by a fixed or removable prosthesis. The subjects were divided into 4 age groups: 16-25, 26-35, 36-45, and ⬎45 years. They also were categorized according to completed education (primary, high school, or higher education). The study involved a clinical examination in which chief complaints were recorded and existing and missing teeth were charted. Missing teeth were classified as anterior and posterior so that a distinction could be made between esthetic and functional needs. Since premolars are important for both esthetics and function, they were included in both classifications. The average number of missing teeth was recorded. The clinical examination was followed by a questionnaire that contained 3 yes/no questions on tooth loss and its effects (Table I). Responses to the second and third questions were considered subjective estimations 572
of esthetic and functional needs, respectively. A professional assessment of patient needs was derived with the following criteria: at least 1 missing anterior tooth (incisor, canine, or premolar) constituted a need for esthetic restoration; at least 3 missing posterior teeth (premolar, first molar, second molar) constituted a need for functional restoration. If subjects did not perceive a need for treatment but professional assessment indicated otherwise (positive need), the outcome was categorized as underestimation. If subjects perceived a need for treatment but professional assessment indicated otherwise (negative need), the outcome was categorized as overestimation. Probabilities of overestimation for each age group and educational level were calculated with the following formula: No. of subjects (overestimations) ⫻ 100 Total no. of subjects (negative professionally assessed need) Similarly, probabilities of underestimation for each age group and educational level were calculated as follows: No. of subjects (underestimations) ⫻ 100 Total no. of subjects (positive professionally assessed need) On the basis of the perceived data, a 2-tailed t test with Bonferroni correction was used to determine differences in the number of missing teeth among the groups. Perceived need was compared to professionally assessed need according to the 4 age groups and 3 educational levels with McNemar’s statistical test at the 5% level of significance.
RESULTS Eighty-seven subjects (37%) had undergone prosthetic treatment for missing teeth (62 fixed and 25 removable prostheses). The distribution of subjects by age and education level is shown in Figure 1. Education at the highest level was inversely proportional to age. The mean number of missing teeth per subject was 4.2 ⫾ 4.9. In subjects with no perceived need for tooth replacement, an increased number of missing posterior teeth was associated with age (Fig. 2). No such trend was found for anterior teeth in relation to age (Fig. 3). In subjects with a perceived need for tooth replacement, the number of anterior and posterior missing teeth increased with age. The mandibular first molar was the most commonly missing tooth followed by the mandibular second molar (Fig. 4). The frequency of missing anterior teeth was low compared to posterior teeth. Responses to the 3 subjective questions are shown in Table I. An increase in the number of missing teeth was noted in subjects with high perceived need for tooth VOLUME 90 NUMBER 6
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Fig. 1. Distribution of age and educational level.
Fig. 2. Mean and standard error of missing posterior teeth according to responses to Q1 in different age groups.
replacement though the trend was not statistically significant (P⫽.68, Table II). Excluding the youngest age group, the average number of missing teeth was significantly higher for subjects who perceived a need for tooth replacement (Figs. 2 and 3). Subjects who perceived no need for tooth replacement still had all teeth remaining in the canine-to-canine region. Table III contains data on patient-perceived and professionally assessed need for esthetic treatment according to age group. Overestimation of esthetic treatment DECEMBER 2003
need showed wide variation and was least in the youngest age group. The range of underestimation of esthetic treatment need was narrower. Overestimation of esthetic treatment need based on education level fell in a narrow range (Table IV) and was least among the most educated subjects. Underestimation of esthetic treatment need covered a wider range, and was highest in the most educated subjects. Differences in patient perceptions and professional assessments of the need for esthetic treatment were not significant across age and education groups. 573
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Fig. 3. Mean and standard error of missing anterior teeth according to responses to Q1 in different age groups.
Fig. 4. Graphic presentation of presence of mandibular teeth.
Table V shows the distribution of patient-perceived and professionally assessed need for functional treatment among the different age groups. Underestimation of functional treatment need covered a wide range and was highest in the youngest age group. Overestimation of functional treatment need was highest in the oldest 574
age group (⬎45 years), but the difference between patient-perceived and dentist-assessed need was not significant. However, this difference was significant in the 2 younger age groups. Table VI shows the distribution of patient-perceived and professionally assessed need for functional treatment based on education level. OveresVOLUME 90 NUMBER 6
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Table III. Two-by-two table of perceived esthetic need (question 2) and professionally assessed esthetic need in different age groups
Age group
Professionally assessed esthetic need
Perceived esthetic need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes No Yes
34 5 26 11 15 11 15 6
8 15 8 15 14 19 12 23
.581
13
35
.648
30
35
.690
42
42
.238
29
34
16-25 26-35 36-45 ⬎45 *McNemar test (P ⬍ .05).
Table IV. Two-by-two table of perceived esthetic need (question 2) and professionally assessed esthetic need by different educational levels
Education level
Professionally assessed esthetic need
Perceived esthetic need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes
13 6 28 14 49 13
8 20 16 37 18 15
.791
32
29
.855
33
30
.472
21
55
Primary High school Higher education *McNemar test (P ⬍ .05).
Table V. Two-by-two table of perceived functional need (question 3) and professionally assessed functional need in different age groups
Age group
Professionally assessed functional need
Perceived functional need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes No Yes
28 22 16 21 13 16 6 11
7 5 6 17 7 23 5 34
.009
44
58
.007
57
26
.093
55
23
.210
65
13
16–25 26–35 36–45 ⬎45 *McNemar test (P ⬍ .05).
timation of functional treatment need was least in subjects who had only a primary education, while underestimation of need covered a narrower range. Differences between patient perceptions and professional assessments of the need for functional treatment were significant in the high school and higher education groups.
DISCUSSION In recent years, the importance of patient-mediated concerns in prosthetic treatment planning, especially in DECEMBER 2003
regard to the replacement of missing teeth, has appeared to be gaining momentum.9,10 This study aimed to explore the possible relationship that might exist among a group of male Saudi dental patients between the subjective need for tooth replacement and professionally assessed prosthetic treatment need. For the purpose, patients’ concerns with respect to their missing teeth, with particular reference to their stated reasons for needing to have their teeth replaced, were obtained, while normative prosthetic treatment need was based on the number 575
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Table VI. Two-by-two table of perceived functional need (question 3) and professionally assessed functional need by different educational levels
Education level
Primary High school Higher education
Professionally assessed functional need
Perceived functional need
Negative
Positive
No Yes No Yes No Yes
10 5 24 31 29 34
7 25 11 29 7 25
P value*
Overestimation %
Underestimation %
.774
33
22
.003
56
28
⬍.001
54
22
*McNemar test (P ⬍ .05).
of missing teeth in the anterior and posterior regions. Other esthetic and functional factors, such as the extent of the exposed anterior edentulous space and the position of missing posterior teeth, were not considered. Osterberg et al21 reported that esthetic rather than functional factors determined an individual’s subjective need for the replacement of missing teeth. In the present study, patients of all ages were more concerned with the replacement of anterior teeth than posterior teeth, which is in agreement with the findings of several other studies.1,6,7,20-23 Perceptions of the effect of missing teeth on subjects’ appearance varied among subjects. Thirty-three subjects (14%) believed that their appearance was affected by missing molars (Table III) while 42 subjects (18%) had no esthetic concerns about missing premolars. This is in agreement with earlier studies that reported wide variations in the impact of tooth loss.5,18,19 In a Malaysian study,24 subjects were not concerned about the replacement of missing teeth, regardless of whether they were in the anterior or posterior region. Liedberg et al7 found a high prevalence of edentulous spaces in the premolar and molar regions in a Swedish population, but the subjects showed no perceived need for replacement. These findings could be attributed to cultural differences among different populations. In the present study, a similar trend in subjective need for replacing posterior teeth (premolars and molars) was found. Rosenoer and Sheiham10 stated that the measure of treatment need should include the perception and attitude of patients to the planned treatment. They found that dental impact, which includes the subjective response of patients to function and esthetics, was highly correlated with the number of natural teeth present. In the present study, patient concerns about esthetics and function did not always match the objective assessment, but this finding may be a reflection of the questionnaire utilized. A different form of inquiry may produce a different outcome. A few patients expressed an unrealistic esthetic concern for a missing molar, but others had functional concerns when they had lost only 1 posterior tooth. Other studies have shown that a complete com576
plement of teeth is not necessary for adequate function or patient satisfaction.7,10,12,14-17 Some participants in the present study overestimated treatment need to a greater extent than subjects in a previous study.2 On the other hand, others did not state a need to replace several missing teeth in the anterior and posterior regions. Kayser et al13 proposed a problem-oriented approach to treatment planning, in which missing teeth should be replaced only if they caused esthetic and functional problems. The results from the present study revealed a discrepancy between subjective and objective assessment of both esthetic and functional problems. This is in agreement with the results of Smith and Sheiham,2 who stated that the criteria used by patients to assess their own oral health were poorly correlated with those used by a dentist. Although there was disagreement between patientperceived need and professionally assessed need in several patients, the difference between the need for functional restoration was statistically significant while that for esthetic restoration was not. This may reflect the existence of a clinical condition in these patients in which the dentist and patient are more likely to agree about esthetic needs than functional needs, perhaps the presence of visible spaces. Several explanations could be offered for the apparent pattern of disparities between patient/dentist assessments observed. First, patients’ perceived needs are widely variable and cannot be predicted from the number or position of missing teeth alone (Figs. 1 and 2). This corroborates previous findings that an individual’s satisfaction with his/her oral condition, status, and appearance was not related to the number of teeth.9,10 Second, patients could demand tooth replacement for reasons other than perceived functional or esthetic need. Factors such as the misconception that a complete compliment of teeth is necessary for oral function, advice from other dentists, and the desire for a feeling of completeness may play a role in such demands for replacement. Third, the availability of free dental treatment in Saudi Arabia may have influenced the results of this study by exaggerating treatment demand. Treatment VOLUME 90 NUMBER 6
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cost has been shown to influence patient decisions about replacing missing teeth.2,10 The results of the present study showed that patients both underestimated and overestimated prosthetic treatment need. Factors other than esthetics and function may have contributed to perceived need for tooth replacement, but these were not investigated. It should be noted that the results of this study are applicable only to the Saudi male population evaluated and cannot be generalized to other populations. Even though similar results might be found in countries with socioeconomic conditions such as those of Saudi Arabia, the hypothesis requires further research.
CONCLUSIONS Within the limitations of this study on Saudi male patients, the following conclusions were drawn: 1. Patients’ perceived need to replace missing teeth was positively associated with the number of missing teeth, except in the youngest age group (16-25 years). 2. A wide range of overestimation and underestimation of treatment needs were observed in the sample, based on the criteria used in clinical assessment. 3. Clinically assessed functional need was significantly different from patient-perceived functional need. The author thanks Professor Ridwan Omar and Dr. Mohammed Aleem Abdullah for reviewing the manuscript.
REFERENCES 1. Bjorn AL, Owall B. Partial edentulism and its prosthetic treatment within a Swedish population. Swed Dent J 1979;3:15-25. 2. Smith JM, Sheiham A. Dental treatment needs and demands of an elderly population in England. Community Dent Oral Epidemiol 1980;8:360-4. 3. Palmqvist S, Soderfeldt B, Arnbjerg D. Self-assessment of dental conditions: validity of a questionnaire. Community Dent Oral Epidemiol 1991; 19:249-51. 4. Vigild M. Denture status and need for prosthodontic treatment among institutionalized elderly in Denmark. Community Dent Oral Epidemiol 1987;15:128-33. 5. Locker D, Slade G. Association between clinical and subjective indicators of oral health status in an older adult population. Gerodontology 1994; 11:108-14. 6. Tervonen T, Knuuttila M. Awareness of dental disorders and discrepancy between “objective” and “subjective” dental treatment needs. Community Dent Oral Epidemiol 1988;16:345-8. 7. Liedberg B, Norlen P, Owall B. Teeth, tooth spaces, and prosthetic appliances in elderly men in Malmo, Sweden. Community Dent Oral Epidemiol 1991;19:164-8.
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8. Vigild M. Benefit related assessment of treatment need among institutionalized elderly people. Gerodontology 1993;10:10-5. 9. Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and position of teeth. J Oral Rehabil 1998;25:649-61. 10. Rosenoer LM, Sheiham A. Dental impacts on daily life and satisfaction with teeth in relation to dental status in adults. J Oral Rehabil 1995;22: 469-80. 11. Kayser AF. Limited treatment goals—shortened dental arches. Periodontol 2000 1994;4:7-14. 12. Witter DJ, van Palenstein Helderman WH, Creugers NH, Kayser AF. The shortened dental arch concept and its implications for oral health care. Community Dent Oral Epidemiol 1999;27:249-58. 13. Kayser AF, Battisttuzi P, Snoek PA, Spanauf AJ. The implementation of a problem-oriented treatment plan. Aust Dent J 1988;33:18-22. 14. Meeuwissen JH, van Waas MA, Meeuwissen R, Kayser AF, van’T Hof MA, Kalk W. Satisfaction with reduced dentitions in elderly people. J Oral Rehabil 1995;22:397-401. 15. Witter DJ, Cramwinckel AB, van Rossum GM, Kayser AF. Shortened dental arches and masticatory ability. J Dent 1990;18:185-9. 16. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8:457-62. 17. Agerberg C, Carlsson GE. Chewing ability in relation to dental and general health. Acta Odontol Scand 1981;39:147-53. 18. Sheiham A, Maizels JE, Cushing AM. The concept of need in dental care. Int Dent J 1982;32:265-70. 19. Rosenberg D, Kaplan S, Senie R, Badner V. Relationships among dental functional status, clinical dental measures, and generic health measures. J Dent Educ 1988;52:653-7. 20. Schuurs AH, Duivenvoorden HJ, Thoden van Velzen SK, Verhage F, Makkes PC. Value of the teeth. Community Dent Oral Epidemiol 1990; 18:22-6. 21. Osterberg T, Hedegard B, Sater G. Variation in dental health in 70-yearold men and women in Goteborg, Sweden, A cross-sectional epidemiological study including longitudinal and cohort effects. Swed Dent J 1984;8:29-48. 22. Tervonen T. Condition of prosthetic constructions & subjective needs for replacing teeth in a Finnish adult population. J Oral Rehabil 1988;15:50513. 23. Owall BE, Taylor RL. A survey of dentitions and removable partial dentures constructed for patients in North America. J Prosthet Dent 1989;61: 465-70. 24. Razak IA, Jaafar N, Jalalludin RL, Esa R. Patients’ preference for exodontia versus preservation in Malaysia. Community Dent Oral Epidemiol 1990; 18:131-2. Reprint requests to: DR RIYADH AKEEL PO BOX 60169 RIYADH 11545 KINGDOM OF SAUDI ARABIA FAX: 966-1-419-5367 E-MAIL: [email protected] Copyright © 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 ⫹ 0 doi:10.1016/j.prosdent.2003.09.007
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CLINICAL IMPLICATIONS Within this limited survey of Saudi male patients, some patient concerns were not supported by professional assessments of esthetic and functional treatment needs.
.
D
entists tend to assess the clinical need for prosthetic treatment based on the existence and location of edentulous spaces in the dental arch.1,2 Bjorn and Owall1 noted that missing teeth are replaced primarily for social and esthetic reasons and that treatment decisions cannot be based solely on professional factors. Previous studies2-5 reported a discrepancy between the treatment needs perceived by patients and those assessed by dental professionals. The reasons for reduced patient demand for prosthetic treatment are numerous, but include the unavailability of dental services, patients’ financial status, and cultural habits.6-8 A growing recognition that more emphasis be placed on patient-mediated concerns in prosthetic treatment planning is apparent from the literature.9,10 Kayser11 suggested that the need to replace teeth, when it is based solely on the dentist’s presumptions of the impact that Presented at the International College of Prosthodontists meeting, in collaboraton with the 8th annual Convention of Lebanese University, Beriut, Lebanon, September 2000. a Chairman, Department of Prosthetic Dental Sciences. DECEMBER 2003
morphological shortfalls could have, may amount to overtreatment. He introduced the concept of the shortened dental arch, which has gained popularity in the last 2 decades.12-17 Consequently, more information has been published on realistic treatment needs8 and sociodental treatment needs of different populations.2,18,19 These concepts suggest that limited treatment may be acceptable for patients with no perceived need for tooth replacement. Patients who express subjective needs for prosthetic treatment may be a higher priority.10 Perceived needs for tooth replacement are based on esthetic, social, functional, and cultural factors.20-23 According to data gathered in previous reports, many patients find the 6 anterior teeth indispensable but will accept edentulous spaces in the posterior regions of the mouth.1,6,7,20-23 Several studies have reported that patients underestimate their treatment needs3,9,10,22 There is no published evidence, however, that patients overestimate treatment needs. The aims of this study were: (1) to document the perceived prosthetic treatment needs of a limited sample of Saudi male patients and the factors THE JOURNAL OF PROSTHETIC DENTISTRY 571
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Table I. Distribution of responses to 3 yes/no questions Questions
Yes: number (%)
Do you think you need to replace the missing tooth (teeth)?* Do you think losing your tooth (teeth) has affected your appearance? Do you think losing your tooth (teeth) has affected your ability to chew food?
No: number (%)
194 (82)
43 (18)
105 (44)
133 (56)
150 (63)
88 (37)
*One subject did not respond.
Table II. Distribution of responses to Question I according to number of missing teeth* No. of missing teeth
1 2–3 4–6 ⬎6
Need to replace: number (%)
Do not need to replace: number (%)
52 (74) 58 (76) 47 (89) 37 (97)
18 (26) 18 (24) 6 (11) 1 (3)
*One subject did not respond. Chi-square goodness of fit ⫽ 0.68 (NS).
that influenced their perceptions, and (2) to compare these perceived needs to professionally assessed clinical needs.
MATERIAL AND METHODS The study population comprised 238 male subjects selected from the screening clinic of the King Saud University College of Dentistry. To be included in the study, subjects had to be men between the ages of 16 and 77 and have at least 1 missing tooth (excluding third molars) that had not been replaced by a fixed or removable prosthesis. The subjects were divided into 4 age groups: 16-25, 26-35, 36-45, and ⬎45 years. They also were categorized according to completed education (primary, high school, or higher education). The study involved a clinical examination in which chief complaints were recorded and existing and missing teeth were charted. Missing teeth were classified as anterior and posterior so that a distinction could be made between esthetic and functional needs. Since premolars are important for both esthetics and function, they were included in both classifications. The average number of missing teeth was recorded. The clinical examination was followed by a questionnaire that contained 3 yes/no questions on tooth loss and its effects (Table I). Responses to the second and third questions were considered subjective estimations 572
of esthetic and functional needs, respectively. A professional assessment of patient needs was derived with the following criteria: at least 1 missing anterior tooth (incisor, canine, or premolar) constituted a need for esthetic restoration; at least 3 missing posterior teeth (premolar, first molar, second molar) constituted a need for functional restoration. If subjects did not perceive a need for treatment but professional assessment indicated otherwise (positive need), the outcome was categorized as underestimation. If subjects perceived a need for treatment but professional assessment indicated otherwise (negative need), the outcome was categorized as overestimation. Probabilities of overestimation for each age group and educational level were calculated with the following formula: No. of subjects (overestimations) ⫻ 100 Total no. of subjects (negative professionally assessed need) Similarly, probabilities of underestimation for each age group and educational level were calculated as follows: No. of subjects (underestimations) ⫻ 100 Total no. of subjects (positive professionally assessed need) On the basis of the perceived data, a 2-tailed t test with Bonferroni correction was used to determine differences in the number of missing teeth among the groups. Perceived need was compared to professionally assessed need according to the 4 age groups and 3 educational levels with McNemar’s statistical test at the 5% level of significance.
RESULTS Eighty-seven subjects (37%) had undergone prosthetic treatment for missing teeth (62 fixed and 25 removable prostheses). The distribution of subjects by age and education level is shown in Figure 1. Education at the highest level was inversely proportional to age. The mean number of missing teeth per subject was 4.2 ⫾ 4.9. In subjects with no perceived need for tooth replacement, an increased number of missing posterior teeth was associated with age (Fig. 2). No such trend was found for anterior teeth in relation to age (Fig. 3). In subjects with a perceived need for tooth replacement, the number of anterior and posterior missing teeth increased with age. The mandibular first molar was the most commonly missing tooth followed by the mandibular second molar (Fig. 4). The frequency of missing anterior teeth was low compared to posterior teeth. Responses to the 3 subjective questions are shown in Table I. An increase in the number of missing teeth was noted in subjects with high perceived need for tooth VOLUME 90 NUMBER 6
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Fig. 1. Distribution of age and educational level.
Fig. 2. Mean and standard error of missing posterior teeth according to responses to Q1 in different age groups.
replacement though the trend was not statistically significant (P⫽.68, Table II). Excluding the youngest age group, the average number of missing teeth was significantly higher for subjects who perceived a need for tooth replacement (Figs. 2 and 3). Subjects who perceived no need for tooth replacement still had all teeth remaining in the canine-to-canine region. Table III contains data on patient-perceived and professionally assessed need for esthetic treatment according to age group. Overestimation of esthetic treatment DECEMBER 2003
need showed wide variation and was least in the youngest age group. The range of underestimation of esthetic treatment need was narrower. Overestimation of esthetic treatment need based on education level fell in a narrow range (Table IV) and was least among the most educated subjects. Underestimation of esthetic treatment need covered a wider range, and was highest in the most educated subjects. Differences in patient perceptions and professional assessments of the need for esthetic treatment were not significant across age and education groups. 573
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Fig. 3. Mean and standard error of missing anterior teeth according to responses to Q1 in different age groups.
Fig. 4. Graphic presentation of presence of mandibular teeth.
Table V shows the distribution of patient-perceived and professionally assessed need for functional treatment among the different age groups. Underestimation of functional treatment need covered a wide range and was highest in the youngest age group. Overestimation of functional treatment need was highest in the oldest 574
age group (⬎45 years), but the difference between patient-perceived and dentist-assessed need was not significant. However, this difference was significant in the 2 younger age groups. Table VI shows the distribution of patient-perceived and professionally assessed need for functional treatment based on education level. OveresVOLUME 90 NUMBER 6
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Table III. Two-by-two table of perceived esthetic need (question 2) and professionally assessed esthetic need in different age groups
Age group
Professionally assessed esthetic need
Perceived esthetic need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes No Yes
34 5 26 11 15 11 15 6
8 15 8 15 14 19 12 23
.581
13
35
.648
30
35
.690
42
42
.238
29
34
16-25 26-35 36-45 ⬎45 *McNemar test (P ⬍ .05).
Table IV. Two-by-two table of perceived esthetic need (question 2) and professionally assessed esthetic need by different educational levels
Education level
Professionally assessed esthetic need
Perceived esthetic need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes
13 6 28 14 49 13
8 20 16 37 18 15
.791
32
29
.855
33
30
.472
21
55
Primary High school Higher education *McNemar test (P ⬍ .05).
Table V. Two-by-two table of perceived functional need (question 3) and professionally assessed functional need in different age groups
Age group
Professionally assessed functional need
Perceived functional need
Negative
Positive
P value*
Overestimation %
Underestimation %
No Yes No Yes No Yes No Yes
28 22 16 21 13 16 6 11
7 5 6 17 7 23 5 34
.009
44
58
.007
57
26
.093
55
23
.210
65
13
16–25 26–35 36–45 ⬎45 *McNemar test (P ⬍ .05).
timation of functional treatment need was least in subjects who had only a primary education, while underestimation of need covered a narrower range. Differences between patient perceptions and professional assessments of the need for functional treatment were significant in the high school and higher education groups.
DISCUSSION In recent years, the importance of patient-mediated concerns in prosthetic treatment planning, especially in DECEMBER 2003
regard to the replacement of missing teeth, has appeared to be gaining momentum.9,10 This study aimed to explore the possible relationship that might exist among a group of male Saudi dental patients between the subjective need for tooth replacement and professionally assessed prosthetic treatment need. For the purpose, patients’ concerns with respect to their missing teeth, with particular reference to their stated reasons for needing to have their teeth replaced, were obtained, while normative prosthetic treatment need was based on the number 575
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Table VI. Two-by-two table of perceived functional need (question 3) and professionally assessed functional need by different educational levels
Education level
Primary High school Higher education
Professionally assessed functional need
Perceived functional need
Negative
Positive
No Yes No Yes No Yes
10 5 24 31 29 34
7 25 11 29 7 25
P value*
Overestimation %
Underestimation %
.774
33
22
.003
56
28
⬍.001
54
22
*McNemar test (P ⬍ .05).
of missing teeth in the anterior and posterior regions. Other esthetic and functional factors, such as the extent of the exposed anterior edentulous space and the position of missing posterior teeth, were not considered. Osterberg et al21 reported that esthetic rather than functional factors determined an individual’s subjective need for the replacement of missing teeth. In the present study, patients of all ages were more concerned with the replacement of anterior teeth than posterior teeth, which is in agreement with the findings of several other studies.1,6,7,20-23 Perceptions of the effect of missing teeth on subjects’ appearance varied among subjects. Thirty-three subjects (14%) believed that their appearance was affected by missing molars (Table III) while 42 subjects (18%) had no esthetic concerns about missing premolars. This is in agreement with earlier studies that reported wide variations in the impact of tooth loss.5,18,19 In a Malaysian study,24 subjects were not concerned about the replacement of missing teeth, regardless of whether they were in the anterior or posterior region. Liedberg et al7 found a high prevalence of edentulous spaces in the premolar and molar regions in a Swedish population, but the subjects showed no perceived need for replacement. These findings could be attributed to cultural differences among different populations. In the present study, a similar trend in subjective need for replacing posterior teeth (premolars and molars) was found. Rosenoer and Sheiham10 stated that the measure of treatment need should include the perception and attitude of patients to the planned treatment. They found that dental impact, which includes the subjective response of patients to function and esthetics, was highly correlated with the number of natural teeth present. In the present study, patient concerns about esthetics and function did not always match the objective assessment, but this finding may be a reflection of the questionnaire utilized. A different form of inquiry may produce a different outcome. A few patients expressed an unrealistic esthetic concern for a missing molar, but others had functional concerns when they had lost only 1 posterior tooth. Other studies have shown that a complete com576
plement of teeth is not necessary for adequate function or patient satisfaction.7,10,12,14-17 Some participants in the present study overestimated treatment need to a greater extent than subjects in a previous study.2 On the other hand, others did not state a need to replace several missing teeth in the anterior and posterior regions. Kayser et al13 proposed a problem-oriented approach to treatment planning, in which missing teeth should be replaced only if they caused esthetic and functional problems. The results from the present study revealed a discrepancy between subjective and objective assessment of both esthetic and functional problems. This is in agreement with the results of Smith and Sheiham,2 who stated that the criteria used by patients to assess their own oral health were poorly correlated with those used by a dentist. Although there was disagreement between patientperceived need and professionally assessed need in several patients, the difference between the need for functional restoration was statistically significant while that for esthetic restoration was not. This may reflect the existence of a clinical condition in these patients in which the dentist and patient are more likely to agree about esthetic needs than functional needs, perhaps the presence of visible spaces. Several explanations could be offered for the apparent pattern of disparities between patient/dentist assessments observed. First, patients’ perceived needs are widely variable and cannot be predicted from the number or position of missing teeth alone (Figs. 1 and 2). This corroborates previous findings that an individual’s satisfaction with his/her oral condition, status, and appearance was not related to the number of teeth.9,10 Second, patients could demand tooth replacement for reasons other than perceived functional or esthetic need. Factors such as the misconception that a complete compliment of teeth is necessary for oral function, advice from other dentists, and the desire for a feeling of completeness may play a role in such demands for replacement. Third, the availability of free dental treatment in Saudi Arabia may have influenced the results of this study by exaggerating treatment demand. Treatment VOLUME 90 NUMBER 6
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cost has been shown to influence patient decisions about replacing missing teeth.2,10 The results of the present study showed that patients both underestimated and overestimated prosthetic treatment need. Factors other than esthetics and function may have contributed to perceived need for tooth replacement, but these were not investigated. It should be noted that the results of this study are applicable only to the Saudi male population evaluated and cannot be generalized to other populations. Even though similar results might be found in countries with socioeconomic conditions such as those of Saudi Arabia, the hypothesis requires further research.
CONCLUSIONS Within the limitations of this study on Saudi male patients, the following conclusions were drawn: 1. Patients’ perceived need to replace missing teeth was positively associated with the number of missing teeth, except in the youngest age group (16-25 years). 2. A wide range of overestimation and underestimation of treatment needs were observed in the sample, based on the criteria used in clinical assessment. 3. Clinically assessed functional need was significantly different from patient-perceived functional need. The author thanks Professor Ridwan Omar and Dr. Mohammed Aleem Abdullah for reviewing the manuscript.
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8. Vigild M. Benefit related assessment of treatment need among institutionalized elderly people. Gerodontology 1993;10:10-5. 9. Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and position of teeth. J Oral Rehabil 1998;25:649-61. 10. Rosenoer LM, Sheiham A. Dental impacts on daily life and satisfaction with teeth in relation to dental status in adults. J Oral Rehabil 1995;22: 469-80. 11. Kayser AF. Limited treatment goals—shortened dental arches. Periodontol 2000 1994;4:7-14. 12. Witter DJ, van Palenstein Helderman WH, Creugers NH, Kayser AF. The shortened dental arch concept and its implications for oral health care. Community Dent Oral Epidemiol 1999;27:249-58. 13. Kayser AF, Battisttuzi P, Snoek PA, Spanauf AJ. The implementation of a problem-oriented treatment plan. Aust Dent J 1988;33:18-22. 14. Meeuwissen JH, van Waas MA, Meeuwissen R, Kayser AF, van’T Hof MA, Kalk W. Satisfaction with reduced dentitions in elderly people. J Oral Rehabil 1995;22:397-401. 15. Witter DJ, Cramwinckel AB, van Rossum GM, Kayser AF. Shortened dental arches and masticatory ability. J Dent 1990;18:185-9. 16. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8:457-62. 17. Agerberg C, Carlsson GE. Chewing ability in relation to dental and general health. Acta Odontol Scand 1981;39:147-53. 18. Sheiham A, Maizels JE, Cushing AM. The concept of need in dental care. Int Dent J 1982;32:265-70. 19. Rosenberg D, Kaplan S, Senie R, Badner V. Relationships among dental functional status, clinical dental measures, and generic health measures. J Dent Educ 1988;52:653-7. 20. Schuurs AH, Duivenvoorden HJ, Thoden van Velzen SK, Verhage F, Makkes PC. Value of the teeth. Community Dent Oral Epidemiol 1990; 18:22-6. 21. Osterberg T, Hedegard B, Sater G. Variation in dental health in 70-yearold men and women in Goteborg, Sweden, A cross-sectional epidemiological study including longitudinal and cohort effects. Swed Dent J 1984;8:29-48. 22. Tervonen T. Condition of prosthetic constructions & subjective needs for replacing teeth in a Finnish adult population. J Oral Rehabil 1988;15:50513. 23. Owall BE, Taylor RL. A survey of dentitions and removable partial dentures constructed for patients in North America. J Prosthet Dent 1989;61: 465-70. 24. Razak IA, Jaafar N, Jalalludin RL, Esa R. Patients’ preference for exodontia versus preservation in Malaysia. Community Dent Oral Epidemiol 1990; 18:131-2. Reprint requests to: DR RIYADH AKEEL PO BOX 60169 RIYADH 11545 KINGDOM OF SAUDI ARABIA FAX: 966-1-419-5367 E-MAIL: [email protected] Copyright © 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 ⫹ 0 doi:10.1016/j.prosdent.2003.09.007
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