Oral health-related quality of life in subjects with implant-supported prostheses: A systematic review

Accepted Manuscript Title: Oral health-related quality of life in subjects with implant-supported prostheses: A systematic review Authors: Daniel R. Reissmann, Michel Dard, Ragna Lamprecht, Julia Struppek, Guido Heydecke PII: DOI: Reference:

S0300-5712(17)30185-9 http://dx.doi.org/doi:10.1016/j.jdent.2017.08.003 JJOD 2817

To appear in:

Journal of Dentistry

Received date: Revised date: Accepted date:

21-2-2017 9-7-2017 2-8-2017

Please cite this article as: Reissmann Daniel R, Dard Michel, Lamprecht Ragna, Struppek Julia, Heydecke Guido.Oral health-related quality of life in subjects with implant-supported prostheses: A systematic review.Journal of Dentistry http://dx.doi.org/10.1016/j.jdent.2017.08.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Oral health-related quality of life in subjects with implantsupported prostheses: A systematic review Daniel R Reissmanna*, Michel Dardb, Ragna Lamprechtc, Julia Struppekc, Guido Heydecked *

Corresponding author

a

Associate Professor, Department of Prosthetic Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Tel: +49-40-7410-54658; Fax: +49-40-7410-57077; Email: [email protected] b

Adjunct Assistant Professor, Department of Periodontology and Implant Dentistry, College

of Dentistry, New York University, New York, USA and Institut Straumann AG, Basel, Switzerland c

Assistant Professor, Department of Prosthetic Dentistry, Center for Dental and Oral

Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany d

Professor and Chair, Department of Prosthetic Dentistry, University Medical Center

Hamburg-Eppendorf, Hamburg, Germany Short title: Dental implants and quality of life

Abstract Objectives: The aim of the present study was to review the current literature relating to the impact of dental implants on oral health-related quality of life (OHRQoL) in edentulous or partially dentate patients. Keywords: Systematic review; implants; quality of life; patient-reported outcomes Data/Sources: Systematic literature searches were performed in the PubMed, EMBASE, and Cochrane Library databases, using high level MeSH terms. The searches were limited to studies published in English from 1960 to June 11, 2017, reporting OHRQoL outcomes using validated instruments, and having enrolled at least 50 patients. Study selection: After removal of duplicates, a total of 2,827 unique hits were identified. After title, abstract, and full text screening, 63 articles were included in the review presenting findings of 55 individual studies. The provision of implant-supported dentures was associated with a significant increase in OHRQoL in partially dentate and in edentulous patients, with the magnitude of achieved improvement typically being greater for implant-supported dentures than with conventional ones. Furthermore, OHRQoL impairment prior to treatment was strongly associated with OHRQoL improvement. Conclusion: For partially dentate patients, there is not enough evidence that implant-supported FDP are superior in terms of OHRQoL than conventional FDP, but moderate evidence suggests that implant-supported FDP perform better than conventional RDP. In edentulous patients, evidence suggests that only if OHRQoL at baseline is highly impaired and patients request implant treatment, IOD are superior than CD in terms of treatment-induced OHRQoL improvement.

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Clinical significance: Patients can be informed that implant treatment is usually related to a significant improvement in OHRQoL. However, improvement is not necessarily higher than for conventional prosthodontic treatments but depends on patient’s clinical and psychosocial characteristics.

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1 Introduction Missing teeth are a common problem among adults of all ages, with the annual incidence of subjects losing ≥1 teeth ranging from 1–14% in European countries.1 The prevalence of edentulism typically increases with age; it is therefore a common problem especially in the elderly.1 In the US alone, it is estimated that approximately one-third of adults aged ≥65 years are edentulous.2 Additionally, on a global level, by 2020 an estimated 38 million adults will require one or two complete dentures.3 Tooth loss, and in particular visible tooth loss (i.e., in the aesthetic zone), is associated with aesthetic problems and reductions in oral health-related quality of life (OHRQoL).4 Masticatory ability is also influenced by tooth loss.5 The magnitude of impairment in OHRQoL is related to the number of missing teeth, with studies showing an association between number of missing teeth and reduction in OHRQoL.6,7 Additionally, subjects may be emotionally affected by tooth loss; a Hong Kong-based study reported that tooth loss had a negative effect in terms of food choices, eating in public and forming close relationships.8 A number of treatment options exist for subjects with missing teeth and also for those completely edentulous, including the replacement of a single missing tooth using conventional and implant-supported fixed dental prostheses (FDP) and for partially dentate (also referred to as partially edentulous) or edentulous patients using conventional removable dental prostheses (RDP) or implant-supported overdentures. However, some patients with conventional dentures, particularly wearers of mandibular dentures, may experience looseness or mobility of the denture, differences in salivary flow, oral sensory function and bite force, and an accelerated rate of residual bone resorption.2 Some patients also experience aesthetic as well as functional problems including difficulties in pronouncing certain sounds and chewing problems. Similarly, implants are associated with caveats including higher initial costs and their placement is a more protracted process and involves surgery, both of which may represent barriers for many patients.9-11 However, when it comes to the question what treatment should be chosen, a conventional or an implant-supported prosthesis, the patient perspective is a significant factor in decision-making, with OHRQoL improvement to be expected following implant treatment being a highly relevant information. While findings from single studies might vary or be even contradictory, systematic reviews offer the best way to bring available information together. They allow to rate the methodological quality and potential bias of the single studies and offer a critically condensed summary. Regarding the impact of implant-supported prostheses on OHRQoL, systematic reviews are available for partially dentate and edentulous populations.12-15 A systematic review by Thomason et al. included studies on OHRQoL and patient satisfaction published 1996–2006 in a broad range of subjects including those undergoing single tooth replacement as well as subjects who required reconstruction of the whole jaw.12 The consensus findings were that subjects were more satisfied with implants than conventional dentures and that OHRQoL is significantly improved following the placement of implants. Another systematic review by Strassburger et al. on studies in partially dentate or edentulous subjects published 1960–2003, concluded that the placement of implant-supported mandibular prostheses is associated with an improvement in OHRQoL, but that the placement of more than two implants does not result in further incremental improvements on OHRQoL or patient satisfaction.13,14 Additionally, a 2009 systematic review by Emami et al. analyzed findings from randomized controlled trials of mandibular implant-retained overdentures versus conventional mandibular dentures in edentulous patients.15 While the meta-analysis of patient satisfaction showed a large effect size in favor of implants, the effect in the meta-analysis of OHRQoL did not achieve statistical significance and significant heterogeneity was reported between the studies. Even

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though these reviews provide some evidence for the impact of implant support of prostheses on patient perceptions, the reviews are somewhat outdated and do not consider more recent research findings. The aim of the present study was to review the current literature relating to the impact of dental implants on OHRQoL in edentulous or partially dentate patients, and in particular to compare the relative impact of implant-based prostheses with that of conventional prostheses in terms of OHRQoL.

2 Materials and methods The study was designed following the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) statement.16

2.1 Criteria for considering studies for this review 2.1.1 Type of studies No exclusion criteria in terms of study design were applied; as such cross-sectional, retrospective, and prospective studies were included. Studies could be either observational or randomized controlled trials (RCT).

2.1.2 Types of participants We considered adult male and female subjects for inclusion. Studies that were performed exclusively in pediatric populations were excluded. At least 50 patients had to be enrolled in the studies for inclusion.

2.1.3 Types of interventions We included any study where at least a subgroup of participants had or received dental implants.

2.1.4 Types of outcome measures For inclusion, studies were required to report OHRQoL outcomes using validated instruments such as (but not limited to) the Oral Health Impact Profile (OHIP),17 the Geriatric Oral Health Assessment Index (GOHAI),18 the UK oral health related quality of life measure (OHQoL-UK),19 or Dental Impact on Daily Living (DIDL)20 questionnaires.

2.1 Search strategy Literature searches were performed using the PubMed, EMBASE, and Cochrane Library databases, together covering most of the scientific literature in the field. The initial search strategy was designed for use in the PubMed database using high level MeSH terms as follows and adapted for use in the EMBASE and Cochrane Library databases: ((((“Dental Prosthesis”[Mesh] OR “Dental Restoration, Temporary”[Mesh] OR “Dental Restoration, Permanent”[Mesh] OR “Dental Implantation”[Mesh] OR “Dental Implants”[Mesh] OR “Mandibular Prosthesis Implantation”[Mesh] OR “Periodontium”[Mesh] OR “Prosthodontics”[Mesh]))) AND (“Quality of life”[Mesh] OR “patient satisfaction” [Mesh])) NOT (Editorial[Publication Type] OR Letter[Publication Type] OR Case Reports[Publication Type] OR Comment[Publication Type] OR Review[Publication Type]). The searches were limited to studies published in English from 1960 to June 11, 2017.

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2.2 Data collection and analysis 2.2.1 Selection of studies Title and abstracts were screened by one review author (RL), while full texts of articles were assessed for inclusion independently by two review author (RL, JS). Disagreement was solved by discussion.

2.2.2 Data extraction and management A pair of review authors independently extracted data using a standardised data collection sheet. The review authors were not blinded to authors of included studies. The two review authors resolved disagreements by discussion or, if necessary, by consulting a third review author (DRR) in order to reach consensus. The following information was recorded where available:

1. Year of publication, authors, and country of origin 2. Primary aim 3. Study design 4. Participants: sample size, age, gender, subgroups 5. Intervention: materials and techniques used, time to follow-up 6. Control: materials and techniques used, time to follow-up 7. Outcomes: primary and secondary outcomes 2.2.3 Assessment of risk of bias in included studies Risk of bias assessment was performed for included studies with highest level of evidence, i.e., RTCs. It followed the guidance in the Cochrane Handbook for Systematic Reviews of Interventions.21 Two review authors (RL, JS) independently assessed and scored studies in order to identify any potential sources of systematic. Judgements concerning the related risk of bias for each domain were assigned as either ’low risk’, ’high risk’, or where insufficient information was available to make a judgement, ’unclear risk’. Additional a ’Risk of bias’ table for included studies is presented.

2.2.4 Data synthesis Due to methodological differences, e.g. different OHRQoL questionnaires or versions, and different characteristics in included studies resulting in substantial heterogeneity a meta-analysis was deemed not indicated. Instead, for better comparison of study findings, standardizes effects sizes (ES) were computed for differences and change scores. These ES allow not only to compare findings of studies with different outcome measures, but also to assess the clinical relevance of the findings. According to guidelines, an ES of 0.2 is considered small, 0.5 is medium, and 0.8 is “large”.22 Furthermore, an ES of 0.5 represents the minimal important difference for many patients reported outcome measures.23

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3 Results 3.1 Description of studies After removal of duplicates a total of 2,827 unique hits were identified. A first-round screen of all titles and abstracts resulted in a short-list of 166 articles for full text review. Following this, a total of 63 articles presenting findings of 55 individual studies were selected for inclusion in the final review (Figure 1). A total of 21 studies were conducted in partially dentate subjects24-42 and two further studies included a mix of edentulous and partially dentate subjects43-45 (Table 1). Furthermore, 32 studies identified in the literature review were conducted in edentulous patients46-84 (Table 2).

3.2 Risk of bias of included RCTs No included RCT showed overall risk of bias (Figure 2). Seven studies had a high risk of bias.42,48,50,57,63,64,68,71,75 The other four studies were at unclear risk of bias.53,56,69,74,84

3.3 Findings for partially dentate subjects 3.3.1 Cross-sectional assessments Four cross-sectional studies without a sufficient control group consistently reported low OHRQoL impairment in partially dentate subjects treated with implant-supported fixed dental prostheses (FDP).38,39,85,86 Another two cross-sectional studies with control groups were identified for partially dentate subjects. These studies revealed that subjects with implant-supported FDP had substantially better OHRQoL compared to subjects with conventional RDP (ES: 0.83),28 but not when compared to subjects with conventional FDP for tooth replacement (ES: 0.38).40

3.3.2 Prospective treatment assessments Several prospective studies assessed the effect of implant treatment on patients’ perceptions. Among them, eighth studies demonstrated that after treatments with implant-supported FDP OHRQoL improved significantly.26,30,32,35,36,41,42,45 Effect sizes for the impact of the new implantsupported FDP on OHRQoL ranged in the studies from 0.49 in patients with short implants in the posterior region42 to 1.2645 and 2.3835 in patients with missing anterior teeth. However, no other treatment options were considered that would allow to compare the specific impact of the implants with conventional dentures to replace missing teeth. Further four studies were identified that compared the effect of implant-supported FDP to either conventional FDP or RDP,25,29,33,34 with the majority observing higher OHRQoL improvement in patients with implant treatment. While treatment with conventional FDP or RDP had no significant short-term effect on OHRQoL in one study (ES: 0.07 and 0.10, respectively), implant-supported FDP substantially improved OHRQoL (ES: 0.43).25 Furthermore, patients who received implants also reported better chewing function (assessed using the Chewing Function Questionnaire; CFQ87) and esthetics (assessed using the Orofacial Esthetic Scale, OES88), with the latter effect especially pronounced in the FDP treatment groups.33 The specific impact of implant-support has also been investigated up to 3 years post treatment with significantly higher treatment effects in patients with

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implant-supported FDP (ES: 3.30) than in patients with conventional FDP (1.62).29 In contrast, one study reported no significant difference in OHRQoL improvement between implant-supported and conventional FDPs.34 However, none of the studies randomly allocated the treatment options to the patients, limiting comparability of treatment effects.

3.3.3 Impacts on treatment effects Ten studies were identified that explicitly assessed the impact of patient characteristics such as personality traits,24 oral status such as number43,44 and location27 of missing teeth that require replacement, or treatment characteristics such as loading protocol,31 implant diameter,85 implant length,42 type of retention,86 or condition of the implant site41 on patients’ perceptions of effects of implant treatment (Table 3). Personality traits (neuroticism, extroversion, openness, agreeableness and conscientiousness; assessed using the NEO-FFI89) significantly influenced the response to implant treatment, in particular neuroticism, which was significantly correlated with implant treatment-induced improvement in OHRQoL.24,36,37 That is, patients with higher levels of neuroticism perceived less satisfactory effects of implant treatment. All of the investigated clinical characteristics affected the treatment effects of dental implants. Improvements in OHRQoL were significantly and positively related to the number of front teeth that were initially missing and replaced by implants.43,44 Furthermore, subjects with tooth loss in the anterior region showed the greatest improvement in OHRQoL following replacement (ES: 1.62) compared to subjects with tooth loss in the molar area (ES: 0.47).27 In contrast, only some treatment characteristics were a significant predictor for differences in treatment effect. One study provided evidence for the effect of the loading protocol on OHRQoL improvement following treatment.31 Patients with immediately loaded implants had on average higher change scores, i.e., more OHRQoL improvement (ES: 2.94) than patients with conventional loaded implants (ES: 0.84). However, other treatment characteristics such as implant diameter (3.3 mm vs 4.1/4.8 mm), implant length (6 mm vs. 11–15 mm), type of retention (cemented vs. screwed), or condition of the implant site (extraction sockets vs. healed alveolar ridges) were not associated with the size of the treatment effect.41,42,85,86

3.4 Findings for edentulous subjects The majority of studies included here compared mandibular implant-supported overdentures (IOD) versus conventional complete dentures (CD) in terms of OHRQoL.46-50,52,53,55-64,67-69,73-77,82 As such, only one study was identified that assessed OHRQoL changes due to maxillary implant-supported overdentures,54 and three studies that did not differentiate between implant support in the mandible or the maxilla.51,65,66

3.4.1 Cross-sectional assessments Six studies were identified with only a single assessment, thus just comparing different patient populations.51,62,65,66,77,82,83 Patients with implant-supported FDP reported slightly better OHRQoL and higher satisfaction than IOD patients, even though differences were statistically significant only in the OHIP-14 domains psychologic discomfort and psychologic disability.51 Another study did not report any significant difference in OHRQoL between patients with implant-supported FDP and IOD.65 When comparing IOD with CD, findings were inconsistent. Satisfaction was significantly higher in the implant group but no significant between-group differences were observed for OHRQoL.62,66 In

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contrast, other studies reported significantly better OHRQoL in patients with IOD than with CD.77,82 Furthermore, patients with mini dental implants had OHRQoL comparable to conventional implant support.83

3.4.2 Prospective treatment assessments Of prospective studies to assess treatment effects, five were identified covering follow-up periods between three months to five years that did not include a sufficient control group.46,49,54,55,67,76 Studies consistently reported OHRQoL improvement in edentulous patients after treatment with a mandibular overdenture. Short-term impact (three to six months post treatment) of implant support on OHRQoL ranged in these studies for two-implant OD from ES: 0.9867 to ES 2.32,55 and was ES: 1.47 for three-implant OD 76. Long-term effects (five years post treatment) were established in another study with patients treated with mandibular overdenture supported by four immediately loaded implants with OHRQoL and patient satisfaction (ES: 2.66) still improved at follow-up compared to baseline.46,49 Further four studies included control groups but did not randomly assign treatment options to the patients.47,61,73,75 Overall, most study showed superiority of IOD over CD in terms of OHRQoL improvement.47,61,73 Treatment effects of IOD (ES: 1.18 and 7.62, respectively) were significantly larger than of CD (ES: 0.46 and 3.52, respectively).47,75 Additionally, of the studies that compared IOD with CD a total of six RCTs have been identified with five reported significant post-treatment between-group differences in favor of implants50,56,57,63,64,68,74 Two to three months after treatment, impact of CD on OHRQoL (ES: 0.24 and 0.28, respectively) was consistently lower than impact of IOD (ES: 1.05 and 0.90, respectively).57,74 In contrast, in one study there were no significant post-treatment differences at 3 months follow-up between the patients receiving CD or patients receiving IOD.48 When longer follow-up periods are considered, previous findings regrading a significant impact of implant support on OHRQoL were confirmed. Patients with IOD had higher treatment effects six months (ES: 1.12 vs. 0.40), twelve months (ES: 1.73 vs. 0.46), and two years (ES: 1.67 vs. 0.03) after treatment than patients with CD.56,63,68 One study included in the present review were conducted exclusively in subjects with head and neck cancer who subsequently required prosthetic dental restorations. The authors noted that the placement of IOD was associated with improvements in most OHIP domains and improvements were notably better in patients who had not undergone radiation treatment in comparison with those who had.58,59 An indeed, while in irradiated patents effects were negligible or even adverse indicated by negative effect sizes, non-irradiated patients perceived substantially higher improvements at 6 months (ES: -0.17 vs. 0.35), 12 months (ES: -0.09 vs. 0.69), and 5 years (ES: 0.22 vs. 0.65) after treatment.

3.4.3 Impacts on treatment effects Additional nine studies were included in this review that investigated the impact of several factors such as atrophy of the maxilla and implant position,70,80,81 implant dimension,71 guided surgery,84 number of implants,78,79 retention system,72,78,79 dietary advices,52 sense of coherence (SOC),53,69 and personality traits60 on treatment effects in terms of OHRQoL and satisfaction (Table 3). Studies revealed a significant association between several treatment characteristics and OHRQoL improvement, even though findings are not consistent. Number of implants and attachment type were associated with OHRQoL with lowest OHIP summary scores observed in patients with 4-

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implant-supported bars and highest scores in patients with two implants and balls.78,79 Similar findings with respect to OHRQoL were observed on another study.72 Three to five years after provision with new IOD, OHRQoL was highest in patients with 4 mini-implants with ball ring matrices, followed by patients with 2 standard implants with locator, and worst in patients with 2 implants with bar-retained IOD. Furthermore, OHRQoL improvement was higher in patients receiving 2 or 4 mini-implants than in patients with 2 standard implants for the support of mandibular IOD.71 However, better results in terms of OHRQoL and satisfaction in patients with miniimplants than in patients with standard implants were associated with considerably lower implant survival rates at 12-months follow-up (4 mini-implants: 89%, 2 mini-implants 82%, and 2 standard implants: 99%). Longer interimplant distance between two implants in the edentulous mandible also positively affected treatment-induced OHRQol improvements 80,81. In contrast, guided surgery or implant position in the maxilla (palatal positioned implants in severely atrophic maxillae vs. wellcentered placed implants in the non-atrophic maxilla) had no impact on OHRQoL.70,84 Customized dietary advice had no meaningful effect on OHRQoL in edentulous patients with CD or IOD.52 Furthermore, SOC was not associated with OHRQoL.53,69 However, OHRQoL was related to personality traits with neuroticism being the most relevant one.60 That is, patients who expressed more neuroticism had on average worse OHRQoL.

4 Discussion The review revealed that there is a substantial number of studies investigating the effect of implant placement on OHRQoL, with the majority of studies performed in edentulous patients. Analysis of the studies included in the present review shows that the provision of implant-supported dentures is associated with a significant increase in OHRQoL in partially dentate and in edentulous patients, with the magnitude of achieved improvement typically being greater for implant-supported dentures than with conventional ones. However, these findings have to be interpreted with caution. In partially dentate patients, the consensus finding among OHRQoL studies is that treatment with implant-supported FDP improves OHRQoL. But this is not surprising since obviously these patients had a demand for prosthodontic treatment. Accordingly, pre-treatment OHRQoL might have been substantially impaired due to tooth gaps or provisional prostheses, and it is well known that the provision of new definitive prostheses has a positive and long-lasting effect on OHRQoL.90 Therefore, the effects of implant-supported FDP on OHRQoL might be related to the prosthodontic replacement of missing teeth rather than a specific impact of the implants. When compared to conventional RDP, implant-supported FDP were associated with better OHRQoL and greater treatment-induced improvements. As a matter of fact, patients with FDP have better OHRQoL than those with RPD, irrespective of implant support.91 Furthermore, both groups are not well comparable since treatments in studies with partially dentate patients were not randomly assigned but based on dental status and patient request. Typically, implant patients have higher levels of education and income.60 For patients with lower socioeconomic status (SES), financial constraints may be barriers to the placement of implants. But simultaneously, OHRQoL is related to SES with a lower magnitude in subjects with lower SES. Interestingly, when comparing treatments with implant-supported and conventional FPD, both significantly improved OHRQoL with no significant difference in the magnitude.34 Therefore, there is no evidence so far for partially dentate patients that implant-supported FDP are superior in terms of patient perceptions than conventional FDP, but moderate evidence suggests that implant-supported FDP perform better than conventional RDP.

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Studies in edentulous patients indicate that treatment with IOD improves OHRQoL, and improvement is slightly higher than for conventional CD. However, this finding was not consistently observed in all studies, and cross-sectional comparisons revealed no significant difference between subjects with IOD or CD. One possible reason might be that patients requesting implant treatment typically experienced more problems related to their oral health.47 Accordingly, the potential improvement is greater than in patients with initially less impaired OHRQoL, what was actually observed in the studies. Not surprising, in patients who are satisfied with their current conventional dentures, implant placement does not add a substantial amount of satisfaction.92 Even in most of the identified RCTs study participants are not well representative for all edentulous subjects since they were recruited based on the consent for implant treatment, i.e., the majority of participants had a request for implant treatment, what is very likely related to substantially impaired OHRQoL. Accordingly, the effects if implants on OHRQoL are greater in patients who request implants than in those who do not. Interestingly, the study by Allen and McMillan showed that even though OHRQoL improvement was greater in patients who requested and received IOD than in those who requested and received CD, post-treatment impairment was still substantially lower in the CD group than in the IOD group.47 Another study showed that if all study participants believe that they would receive conventional dentures, no significant differences between IOD and CD treatment was observed.48 All these findings from studies in edentulous patients suggest, that only if OHRQoL is highly impaired and patients request implant treatment IOD are superior than CD in terms of treatment-induced OHRQoL improvement. After treatment, subjects satisfied with their CD or with their IOD do not necessarily differ in perceived problems related to their oral health. That might also be an explanation while most RCTs did not report follow-up results for longer periods, what would be an indicator for publication bias. The findings of studies included in the current review also suggest that personality traits, especially neuroticism, and treatment characteristics such as number and location of replaced teeth are related to OHRQoL and response to treatment. Subjects with high levels of neuroticism tend to be in a negative emotional state, i.e., they have feelings of guilt, envy, anger, anxiety, and depressed mood more frequently and severely than others.93 It is therefore not surprising that patients who express more neuroticism have on average worse OHRQoL, especially since psychosocial impact is one of the four dimensions of OHRQoL.94,95 Accordingly, high levels of neuroticism can be considered a risk factor for treatment failures, at least for the patient perspective. For partially dentate subjects, the magnitude of OHRQoL improvement after treatment is linked to the number and location of implants to replace missing teeth,27,43,44 with higher improvements for anterior than posterior tooth loss and more teeth replaced. This is not surprising given the positive correlation between number of teeth and OHRQoL and more severely impaired OHRQoL due to anterior than posterior tooth loss.4 Furthermore, effects of location of prosthodontic treatments on OHRQoL improvements are also well known.96 Least treatment effects can be expected for the replacement of missing molars.27 This is obviously related to a low impact of missing molars on OHRQoL, what is represented in the proportion of patients with treatment demand. In a large multicenter study in Japan, only 3% of subjects sought treatment for missing second molars.97 When first and second molars were missing, a condition described as a shortened dental arch (SDA),98 only slightly more than half of the subjects requested prosthodontic replacement of missing teeth. Even though loss of molars is related to OHRQoL impairment, especially in the domain oral functions such as chewing,99 extend of impairment is low compared to effects of missing anterior teeth. Accordingly, for implant-supported FDP to replace missing molars, a treatment effect that can be perceived by the patients can only be expected if OHRQoL was substantially impaired before treatment.

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The findings of the current review are in accordance with previous reviews on this topic, even though number of included studies differed. Thomason et al. identified 74 studies,12 Strassburger et al. 114 studies,13,14 and Emami et al. 10 studies,15 while in the current review 55 studies were included. These differences are in part due to different periods covered by the review or inclusion criteria (e.g., the review by Emami et al.15 analyzed only RTCs of mandibular IOD and CD in edentulous patients). Furthermore, studies had to have at least 50 subjects enrolled to be included in the current review. The consensus findings of these previously conducted reviews were that subjects were more satisfied with implant-supported than with conventional dentures and that OHRQoL is significantly improved following the placement of implants.12-15 This is in accordance with the findings of the current review. However, important aspects regarding effects of implants on OHRQoL are hardly addressed if that, i.e., the prerequisite of substantial OHRQoL impairment before treatment, the requirement of request for implants, and the effect of number and location of implants in partially dentate patients. Therefore, the current review adds important information to the available knowledge on impact of implants on OHRQoL. The period for the search covered 57 years, starting with studies published in 1960. The current review was focused exclusively on studies reporting OHRQoL using validated measures including the full and abbreviated forms of the OHIP, GOHAI, and DIDL. Patient satisfaction and OHRQoL are frequently used synonymously; however, studies reporting patient satisfaction only were not included in the current review as many of these report results only in a qualitative rather than quantitative manner. During the literature review process, it was apparent that a large number of patient satisfaction studies have been published but that substantial heterogeneity exists in terms of the outcome measures used to assess patient satisfaction. The use of a large number of different methods of outcomes assessment measures complicates the comparison of results across different studies. Consequently, the remit of the current literature review was limited to studies reporting OHRQoL using validated outcome measures. However, instruments for general HQoL, such as the SF36100 or the EQ-5D101 often fail to capture subtle changes in QoL associated with a particular oral condition.102,103 In contrast, the OHIP is the most frequently used instrument for assessment of OHRQoL that has the potential to become the standard method,104 ensuring the conduction of methodologically high-quality studies and comparison of findings across these studies. There is also another factor that should be taken into account when interpreting the findings of the studies included in the current review. In the majority of prospective studies, OHRQoL was assessed prior to treatment and post-treatment, with the typical post-treatment assessment made within 12 months of implant placement. A key limitation of using short time frames is that such studies will not capture OHRQoL detriments associated with late implant failures or late complications such as periimplantitis. Furthermore, it is somewhat suspect when elaborate RCTs have only short follow-ups, and data on long-term effects are lacking. One could assume that at later follow-ups difference between treatment options were no longer present and, therefore, findings were not reported. Such form of publication bias is not rare; studies with statistically significant results are more likely to be published than those with no difference between groups.105 In summary, the results of OHRQoL studies suggest that both implant-supported prostheses and conventional dentures are associated with improvements in OHRQoL, with OHRQoL impairment prior to treatment being strongly associated with OHRQoL improvement to be expected. Currently, there is not enough evidence that implant-supported FDP are superior in terms of OHRQoL than conventional FDP in partially dentate patients, but moderate evidence suggests that implantsupported FDP perform better than conventional RDP. In edentulous patients, evidence suggests that only if OHRQoL at baseline is highly impaired and patients request implant treatment, IOD are superior than CD in terms of treatment-induced OHRQoL improvement.

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Tables CFQ, Chewing Function Questionnaire; DIDL, Dental Impact on Daily Living; EuroQoL, European Quality of Life indicator; GOHAI, Geriatric Oral Health Assessment Index; NEO-FFI, Neuroticism Extraversion Openness Five-Factor Inventory; OES, Orofacial Esthetic Scale; OHIP, Oral Health Impact Profile; OHRQoL, oral health-related quality of life; QoLIP, Quality of Life with Implant-Prostheses; VAS, Visual Analogue Scale

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BACQ, Brief Approach/Avoidance Coping Questionnaire; DIDL, Dental Impact on Daily Living; DSQ, Dental/Denture Satisfaction Questionnaire; EORTC, European Organization for Research and Treatment of Cancer; ITT, intention to treat; NEO-FFI, Neuroticism Extraversion Openness Five-Factor Inventory; OHRQoL, oral health-related quality of life; PRO, Patient-Reported Outcome; QoLIP, Quality of Life with Implant-Prostheses; RCT, randomized controlled trial; SEIQoL, Schedule for the Evaluation of Individual Quality of Life; SIQ, Social Impact Questionnaire; SOC, Sense of Coherence; VAS, Visual Analogue Scale

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Figure 1 – Schematic diagram of literature search and screening process

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Acknowledgements This study was in part supported by funding from Straumann AG. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Figure 2 – Risk of bias summary: review authors’ judgements about each risk of bias item for each included RCT

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Figures Articles retrieved from searches (N=3,900) EMBASE (n=1,462) PubMed (n=2,037) Cochrane (n=401) Duplicates removed (n=1073) Unique articles for title and abstract review (n=2,827)

Articles excluded (n=2661)

Articles included for full text review (n=166) Articles excluded (n=103)

Articles included in final review (n=63)

Non-eligible population (n=8) Non-eligible outcome (n=86) Non-eligible intervention (n=5) Fulltext unavailable (n=4)

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Table 1 – Summary of OHRQoL studies on implant-supported prostheses in partially dentate subjects Study (year) Aim

Methods and design

Abu Hantash To investigate the et al. 200624 impact of psychological characteristics on OHRQoL in patients receiving implantsupported single crowns or fixed partial dentures

Prospective, clinical study N=50 patients Assessments: before treatment and 2–3 months after treatment

Subjects Mean age: 43.2 yrs (range: 22–71 yrs) 44.0% female

Measures: OHRQoL and personality traits

Summary findings Personality traits influenced patients’ responses to implants; neuroticism was significantly linked to overall satisfaction (lower levels of neuroticism associated with higher levels of satisfaction).

Instruments: DIDL, NEOFFI Al-Omiri et. al. 201136

Comparison between satisfaction with the dentition and dental prostheses and personal profiles in patients with implantsupported prostheses

Prospective, clinical study N=80 patients Assessment: before treatment and 3 months after rehabilitation

Mean age: 41.0 yrs (range: 18-77 yrs) 47.5% female

Measures: patient satisfaction, personality traits

Patients’ satisfaction with their dentition was higher after implant treatment. Patients’ daily living and satisfaction with implantsupported prostheses were affected by personality traits.

Instruments: DIDL, NEOFFI Al-Omiri et. al. 201237

Alzarea et. al. 201638

Assessment of the relationship between satisfaction with implantsupported fixed rehabilitations, their impacts on daily living, and personality profiles

Cross-sectional study Assessment: > 3 month after treatment

N=100 patients (implant patients: n=50; partially dentate controls: n=50)

Measures: dental satisfaction

Mean age = 44.3 yrs (range = 23–60 yrs)

Instruments: DIDL, NEOFFI

70% female

To investigate OHRQoL of patients with dental implants and periodontal parameters of implants and healthy teeth

Cross-sectional study

N=92 patients

Satisfaction was higher in patients with implants than in the control group. Daily living and satisfaction of patients with implant-supported fixed prostheses were influenced by personality traits.

Assessment: 1 year after treatment

Patients with dental implants Mean age: 43 yrs (range were satisfied with their OHRQoL. 25-68 yrs)

Measures: OHRQoL

47.8% female

Instruments: OHIP-14 Bramanti et al. 201330

Dolz et al. 201431

To determine the impact of implant-supported fixed partial dentures rehabilitation on OHRQoL among partially edentulous patients.

Prospective, clinical study N=50 patients

To compare the effect of implant rehabilitation on HRQoL and OHRQoL when implants are loaded either conventionally or immediately

Prospective, nonrandomized clinical trial

Assessments: before treatment and 2 years after treatment

Mean age: 51.2 yrs (range: 40-70 yrs) 56% female

Measures: OHRQoL

OHRQoL improved after treatment with implantsupported fixed partial dentures, especially in patients with Kennedy class I and IV.

Instruments: OHIP-14

Assessments: before treatment, 3 months after implant placement, and 3–5 months after final restoration Measures: OHRQoL, HRQoL, global oral satisfaction Instruments: OHIP-49, EuroQoL, VAS

N=104 patients (immediate loading group: n=29; conventional loading group: n=75) Mean age: 55.5 yrs (range: not provided) 55.5% female

A significant improvement was observed in OHRQoL and global oral satisfaction but not in HRQoL for both loading groups from baseline to the final evaluation. The improvement in OHRQoL was markedly greater in the patients who received immediately loaded implants. There were no significant differences in the ratings of general oral satisfaction or HRQoL.

25

Study (year) Aim

Methods and design

Fillion et al. 201332

Prospective, clinical study N=176 patients (single Assessments: before and tooth group: n=77; fixed 3–15 months after implant partial denture group: n=75; full prostheses placement group: n=24) Measures: OHRQoL Mean age: 52.0 yrs Instruments: GOHAI (range: 18-84 yrs)

Assessment of OHRQoL improvement in patients who underwent dental implant treatment

Subjects

59.1% female Furuyama et al. 201228

Comparison of OHRQoL in subjects with at least one dental implant and with removable partial dentures

Cross-sectional study Assessments: once at least 1 month’s usage of either treatment Measures: OHRQoL Instruments: OHIP-49

N=188 patients (implantsupported fixed dentures [ID] group: n=79; removable partial dentures [RPD] group: n=109) Mean age: 51.7 yrs [ID] and 66.5 yrs [RPD] (range: not provided)

Summary findings Implant treatment improved OHRQoL of participants. Before treatment, the mean GOHAI scores were lower for participants with fewer teeth. Highest improvement was observed in patients who needed complete dentures. Mean OHIP summary domain scores were significantly higher in subjects with removable partial dentures than in subjects with implantsupported fixed dentures, corresponding to better OHRQoL in the latter group.

55.7% [ID] and 69.7% [RPD] female Goiato et al. 201539

Herrmann et al. 201685

Evaluation of OHRQoL of patients with implantsupported fixed partial dentures.

Comparison of implant survival and OHRQoL of reduced-diameter implants and regulardiameter implants

Cross-sectional study

N=106 patients

Assessments: once Measures: OHRQoL

Mean age: 54.2 yrs (range: not provided)

Instruments: OHIP-14

58.5 % female

Retrospective study

N=311 patients (reduced-diameter implants [test] group: n=107; regular-diameter implants [control] group: n=204)

Assessments: posttreatment (mean follow-up period: 22.4 ± 8.2 months) Measures: OHRQoL Instruments: OHIP-14

The OHRQoL of patients wearing implant-supported fixed partial dentures was high.

There was no significant difference in patients’ OHRQoL between those with reduced-diameter implants or regular-diameter implants.

Mean age: 53.3 yrs [test group] and 60.2 yrs [control group] (range: not reported) 57.9% [test group] and 54.8% [control group] female

Kimura et al. 201225

Assessment of response shift in OHRQoL measures in subjects receiving implant-supported fixed or removable partial dentures

Prospective, clinical study N=138 patients (implantsupported fixed dentures Assessment: before [ID] group: n=78; treatment and after conventional fixed partial treatment completion dentures [FPD] group: Measures: OHRQoL n=37; removable partial dentures [RPD] group: Instruments: OHRQoL n=23) questionnaire by Sonoyama et al.106 Mean age: 61.4 yrs (range: 24–87 yrs) 73.2% female

A significant response shift was reported in subjects with implant-supported fixed partial dentures and fixed partial dentures but not for those with removable partial dentures. Only subjects with implant-supported fixed partial dentures had a significant improvement in OHRQoL, irrespective whether response shift was taken into account.

26

Study (year) Aim

Methods and design

Kriz et al.201244 and Pavel et al. 201243

Prospective, clinical study N=97 patients

Assessment of OHRQoL improvement in patients receiving implant-supported fixed, removable, or complete dentures

Assessment: before implantation and at least 1 month after prosthodontic rehabilitation

Subjects Mean age: 46.9 yrs (range: not provided) 58.8% female

Measures: OHRQoL

Summary findings Implant treatment was associated with improvements in OHRQoL, which was influenced by the number of front teeth replaced with higher improvements when more front teeth were replaced.

Instruments: OHRQoL questionnaire based on GOHAI and OHIP-14 Nickenig et al. 200826

Assessment of OHRQoL in partially edentulous subjects before and after implant treatment

Prospective, clinical study N=343 patients (partially edentulous implant Assessments: before patients [IP]: n=219, fully implantation and 1–2 dentate controls [DC]: months after n=124) prosthodontic rehabilitation Measures: OHRQoL Instruments: OHIP-21

Mean age: [IP] 44.7 yrs (range 19.2–67.6 yrs) and [DC] 45.2 yrs (range 21.3–56.7 yrs)

In the implant group, a significant improvement in OHIP score was reported post-treatment, but OHRQoL after implant treatment was still slightly more impaired than in fully dentate controls.

Gender: not provided Nickenig et al. 201645

Assessment of the impact of dental implants on OHRQoL.

Prospective, multicenter clinical study Assessments: preoperative, intermediate and posttreatment

N=8689 patients

46,7% female

OHRQoL improved after treatment with dental implants and prosthodontic rehabilitation. The most significant improvement was observed in patients with edentulous jaws or anterior single-tooth gaps.

N=71 patients (singletooth implant group: n=35; three-unit FPD: n=36)

After treatment, OHRQoL was rated better than before treatment without significant differences between groups.

Mean age: 48.8 yrs (range: 19-89 years).

Measures: OHRQoL Instruments: OHIP-21 Park et al. 201640

Perea et al. 201586

Comparison of OHRQoL after treatment with single-tooth implants versus three-unit fixed partial dentures for single missing tooth restoration.

Assessment of OHRQoL of cemented implant prostheses for validation of the QoLIP10 questionnaire

Cross-sectional study Assessments: retrospective pretreatment (then test) and posttreatment Measures: OHRQoL

Mean age: 52.2 yrs (range: 40-69 yrs)

Instruments: OHIP-14

69% female

Cross-sectional study

N=84 patients (screwed FDPs supported by 2 implants: n = 35); screwed FDPs supported by 3–5 implant: n=7; cemented FDPs supported by 2 implants: n=36; cemented FDPs supported by 3-5 implants: n=6)

Assessments: once after 1 year of treatment Measures: OHRQoL Instruments: OHIP-14, QoLIP-10

The highest improvement in QoL was assessed for short cemented implant restorations. Patient satisfaction depended on extension and type of retention of the restoration.

Mean age: not provided 57.1% female

27

Study (year) Aim

Methods and design

Persic et al. 201533

Prospective, clinical study N=263 patients (conventional dentures Assessments: before group: n=151; implanttreatment and 3 months supported dentures after prosthodontic group: n=112) rehabilitation Mean age: 62.3 yrs Measures: OHRQoL, (range 27–93 yrs) orofacial esthetics,

Assessment of improvement in orofacial esthetics, chewing function and OHRQoL on different prosthodontic rehabilitation options

chewing function

Subjects

61.6% female

Instruments: OHIP-14, OES, CFQ Petricevic et al. 201229

Assessment of OHRQoL in subjects with implant- and toothsupported fixed partial dentures

Prospective, clinical study N=164 patients (implantsupported fixed partial Assessment: before dentures [ID] group: treatment and at 3 weeks n=64; tooth-supported and 3 years after fixed partial dentures prosthodontic [FPD] group: n=38; rehabilitation control group [CG]: Measures: OHRQoL n=62) Instruments: OHIP-49 Mean age: 46.5 yrs [ID],

Ponsi et al. 201127

Comparison of changes in OHRQoL due to placement of a single implant in different areas (anterior, premolar, and molar areas)

Prospective, clinical study N=80 patients

Summary findings After-treatment, OES, OHIP14, and CFQ scores were significantly better than baseline scores for all types of treatments. Implant support resulted in significantly higher improvements in OHRQoL, orofacial esthetics, and chewing function than for conventional dentures.

Baseline OHIP score were significantly higher (worse) in the implant group versus the fixed partial denture and the control group. OHRQoL was significantly improved 3 weeks after prosthodontic treatment in both treatment groups, and further improved 57.6 yrs [FDP], and 42,3 to 3 years post treatment. Even though decrease in yrs [CG] (range 28–74 OHIP scores was higher in yrs) patients with implant 43.8% [ID], 63.2% support, OHRQoL was still [FPD], and 69.4% [CG] more impaired after female treatment than in patients with tooth-supported dentures.

Assessment: after implant Mean age: 52 yrs placement before (range: 24–75 yrs) uncovering and 3 months 64% female after prosthodontic rehabilitation Measures: OHRQoL

In the total population, mean OHIP score improved significantly following treatment. However, OHRQoL improvement was only significant for replaced anterior teeth or premolars but not for molars.

Instruments: OHIP-14 Raes et al. 201241

Comparison of OHRQoL of patients with single implants after placement in extraction sockets with placement in healed alveolar ridges

Case-control study Assessment: at baseline and 1, 6, and 12 months after treatment Measures: OHRQoL Instruments: OHIP-14

Swelem et al. 201434

Investigation of changes in OHRQoL in partially edentulous patients after different types of treatment with toothsupported and implantsupported dentures

N=96 patients (extraction group: n=46; healed ridge group: n=50) Mean age: 43 yrs (range: 18-72 yrs)

OHRQoL improved in both treatment groups. There was no significant difference in OHIP-scores between groups.

57.3% female

Prospective, clinical study N=200 patients (toothsupported fixed dental Assessment: before prostheses group: n=32; treatment and 6 weeks removable dental and 6 months after prostheses group: prosthodontic n=111; implantrehabilitation supported fixed dental Measures: OHRQoL prostheses group: n=57) Instruments: OHIP-14 Mean age: 41.8 yrs

All treatments produced significant improvements in OHRQoL. Changes in OHIP summary scores were comparable in patients treated with either toothsupported or implantsupported fixed dental prostheses.

(range: 30–50 yrs) 50.0% female

28

Study (year) Aim

Methods and design

Subjects

Summary findings

Thoma et al. 201542

Prospective, RCT

N=101 patients

Assessment: at baseline, at suture removal, at prosthesis insertion, and at 1-year follow-up

Mean age: 50.5 yrs (range: 20-75 yrs)

The implant survival rate was 100%. OHIP summary scores decreased in both groups between baseline and follow-up.

Comparison of OHRQoL and implant survival rate of short (6 mm) versus long (11-15 mm) dental implants in combination with sinus grafting

51.5 % female

Measures: OHRQoL, implant survival Instruments: OHIP-49 Yu et al. 201335

Investigation of the relationship between anterior teeth implantation and OHRQoL improvement

Prospective, clinical study N=238 patients Assessment: before implantation and at 6 months after prosthodontic rehabilitation

Mean age: 41.5 yrs (range: 29–56 yrs) 55.9% female

Measures: OHRQoL, implant restorationrelated satisfaction Instruments: OHIP-14, satisfaction items

In patients with partial removable dentures for anterior teeth loss who seek replacement of these dentures, treatment with implant-supported fixed dental prostheses significantly improved OHRQoL. Most patients were satisfied with treatment result.

Table 2 – Summary of OHRQoL studies on implant-supported prostheses in edentulous subjects Study (year)

Aim

Methods and design

Subjects

Summary findings

Attard et al. 200649 and Alfadda et al. 200946

Assessment of clinical and patient-reported outcomes 5 years after placement of mandibular implantsupported overdentures with immediate loading

Prospective, clinical study

N=77 patients (n=35 patients with data on PROs)

One year after treatment, there was a statistically significant improvement in total and functional dental satisfaction scores and in OHRQoL. Initial improvements were maintained over five years.

Assessment: before treatment and at 1 and 5 Mean age: 64.1 yrs years after prosthodontic (range: not reported) rehabilitation 39.1% female Measures: OHRQoL, dental satisfaction Instruments: OHIP-20, DSQ

Allen et al. 200173

Assessment of the impact of preoperative expectations and implant-stabilized prostheses versus conventional prostheses on oral health status

Prospective, clinical study Assessment: before treatment and 3 months after prosthodontic rehabilitation Measures: OHIP, denture satisfaction, expectations of implant therapy Instruments: OHIP-49, DSQ

N=75 patients (implant denture [ID] group: n=20; conventional denture group 1 [CD1]: n=20; conventional denture group 2 [CD2]: n=35)

Preoperative, satisfaction in the three groups was very low. At 3 months after treatment, the three groups had a higher denture satisfaction and decreased OHIP summary scores. The expectation levels preoperative did not influence Mean age: 55.8 yrs [ID], the satisfaction. 60.2 yrs [CD1], and 65.1 yrs [CD2] (range: not reported) 85.0% [ID], 55.0% [CD1], and 74,3% [CD2] female

29

Study (year)

Aim

Methods and design

Subjects

Summary findings

Allen et al. 200648

Assessment of implantretained overdentures (2 implants) versus conventional complete dentures reporting clinical and OHRQoL outcomes

Prospective, RCT

N=118 patients (implant denture [ID] group: n=62; conventional denture [CD] group: n=56)

At 3 months after treatment, there were significant improvements in OHRQoL and denture satisfaction in both groups versus baseline. However, no significant differences between treatment groups were observed.

Assessment: before treatment and at 3 months after treatment Measures: OHRQoL, denture satisfaction Instruments: OHIP-49, DSQ

Allen and McMillan 200347

Clinical trial of the impact of oral implants on OHRQoL

Prospective, clinical trial Assessment: pre- and posttreatment Measures: HRQoL, OHRQoL, denture satisfaction Instruments: OHIP-49, DSQ, SF-36

Mean age: 64.5 yrs [ID] and 68.5 yrs [CD] (range: not reported) 71.1% [ID] and 71.7% [CD] female N=103 patients (implant denture [ID] group: n=26; conventional denture implant request [CD1] group: n=22; conventional denture [CD2] group: n=35; dentate control [DG] group: n=20)

Subjects requesting implants had lower baseline OHRQoL versus patients requesting conventional dentures. Effect size for change in OHIP score was large for the group receiving implants and small for both groups receiving conventional dentures.

Mean age: 58.7 yrs [ID and DG], 60.2 yrs [CD1], and 65.1 yrs [CD2] (range: not provided) 88.5% [ID], 54.5% [CD1], 74.3% [CD2], and 30.0% [DG] female Awad et. al. 200074

Comparison of OHRQoL in patients with mandibular implant-supported overdentures and patients with conventional prostheses

Prospective, RCT Assessment: pre- and 2 month posttreatment Measures: OHRQoL Instruments: OHIP, VAL

N=102 patients (conventional denture [CD] group: n=48; implant overdenture [IOD] group: n=54)

The assessment indicates that patients with implants have a more positive OHRQoL compared to conventional therapy.

Mean age: not provided (range: 35-65 yrs) 49% female

Awad et al. 2003,50 Heydecke et al. 2003,68 and Heydecke et al. 200556

Comparison of patient satisfaction, OHRQoL, and HRQoL in elderly subjects receiving mandibular 2-implant supported overdentures or conventional dentures

Prospective, RCT Assessment: before treatment and 2, 6, and 12 months after treatment

N=60 patients (conventional denture [CD] group: n=30; implant overdenture [IOD] group: n=30)

Measures: OHRQoL, dental satisfaction, HRQoL

Mean age: 69.4 yrs [CD] and 68.9 yrs [IOD] (range 65–75 yrs)

Instruments: OHIP-49, VAS, SF-36

60.0% [CD] and 53.3% [IOD] female

At 2 months post treatment, subjects who received implants had higher satisfaction than subjects who received conventional dentures. Post-treatment OHIP score was significantly better in subjects receiving implants in comparison with those receiving conventional dentures. However, effects of implant treatment on HRQoL were only significant for subscales Role Emotional, Vitality, and Social Function.

30

Study (year)

Aim

Methods and design

Awad et al. 201461

Comparison of OHRQoL in subjects receiving 2-implant supported mandibular overdentures and conventional dentures

Prospective, multicenter, N=203 patients (implant non-randomized denture [ID] group: controlled trial n=104; conventional denture [CD] group: Assessment: at baseline n=99) and 6 months after treatment Measures: OHRQoL

Brennan et al. 201051

Candel-Marti et al. 201570

Subjects

Mean age: 68.8 yrs (range: not provided)

Instruments: OHIP-20

61.4% [ID] and 57.4% [CD| female

Comparison of OHRQoL and patient satisfaction in subjects receiving implantsupported overdentures and implant-supported fixed dentures

Cross-sectional study

N=62 patients (implantsupported overdenture [IOD] group: n=25; implant-supported fixed denture [IFD] group: n=37)

Comparison of OHRQoL and satisfaction in patients with palatal positioned implants and with wellcentered implants supporting fixed fullarch prostheses

Cross-sectional study

Assessment: after treatment (no exact follow-up time reported) Measures: OHRQoL, satisfaction Instruments: OHIP-14, VAS

Assessment: 5-11 years after implant treatment Measures: OHRQoL, satisfaction Instruments: OHIP-14, VAS

Summary findings The proportion of patients who showed improved OHIP-20 scores at 6 months was higher in the groups receiving implants in comparison with those receiving conventional dentures.

Overdenture group reported lower overall satisfaction and satisfaction with chewing ability and esthetics versus subjects with fixed prostheses. Overall OHRQoL was high in both groups; subjects in the Mean age: 57.5 yrs [IOD] and 56.0 yrs [IFD] fixed prostheses group had significantly lower levels of (range: not provided) psychological discomfort and 56.0% [IOD] and 67.6% psychological disability versus [IFD] female overdenture subjects. N=57 patients (palatal positioned implants [PI] group: n=32; wellcentered implants [CI] group: n=25)

Satisfaction and quality of life were high and similar in both groups.

Mean age: 55.0 yrs [PI] and 55.9 yrs [CI] (range: not provided) 75% [PI] and 48% [CI] female

Cakir et. al. 201475

Comparison of satisfaction and QoL in in subjects receiving mandibular complete dentures, implantretained overdentures, removable partial dentures, or implantsupported fixed partial dentures

Prospective, RCT Assessment: before treatment and 1 yr after treatment Measures: QoL Instruments: OHIP-14, OHQoL-UK, SF-36

N=116 patients (implant-retained overdentures n=29, implant-supported FPDs n=29, conventional complete dentures n=29, or RPD n=29)

OHRQoL improved in all groups at post-treatment. Highest improvement was observed in the implantretained overdenture group.

Mean age: 58.0 yrs (range: 36-81 yrs) 54.3% female

De Souza et al. 201571

Comparison of mandibular overdentures retained by 2 or 4 mini-implants with standard implants

Prospective, RCT

N=120 patients (4 miniimplants [4MI] group: Assessment: before intervention and 3, 6 and n=38; 2 mini-implants [2MI] group: n=42; 2 12 months after standard implants [2SI] treatment group: n=40) Measures: OHRQoL, Mean age: 59.3 yrs satisfaction [4MI], 59.1 yrs [2MI], Instruments: OHIPand 60.2 yrs [2SI] EDENT, VAS (range: not provided)

OHRQoL and satisfaction improved in all groups posttreatment, with most favorable results in patients with miniimplant-retained mandibular overdentures. However, the provision of mini-implants was associated with considerably higher implant failure rate than observed for standard implants.

68,4% [4MI], 71,4% [2MI] and 62,5% [2SI] female

31

Study (year)

Aim

Methods and design

Subjects

Summary findings

Ellis et al. 201052

To investigate the impact of dietary advice in subjects with 2implant-supported mandibular overdentures and conventional dentures

Prospective, clinical study

N=54 patients (implantsupported overdenture [IOD] group: n=28; conventional denture [CD] group: n=26)

At 6 months, the implant group had significantly better satisfaction scores in terms of denture comfort, stability and chewing ability. However, there was no significant between-group difference in OHRQoL.

Assessment: before intervention and 6 months after dietary advice was provided Measures: OHRQoL, satisfaction

Emami et al. 201053 and Jabbour et al. 201269

Emami et al. 201576

Mean age: 65.4 yrs [IOD] and 70.6 yrs [CD] (range: not provided)

Instruments: OHIP-20, denture satisfaction scale

71.4% [IOD] and 69.2% [CD] female

To assess influence of sense of coherence on OHRQoL for implantsupported overdentures versus conventional dentures and to determine the stability and magnitude of the effect on OHRQoL

Prospective, RCT

N=173 patients (implant-supported overdenture [IOD] group: n=97; conventional denture [CD] group: n=76)

Assessment of OHRQoL in subjects receiving mandibular three-implant overdentures

Prospective, clinical study

Assessment: before treatment, and 1 and 2 years after treatment Measures: OHRQoL, SOC Instruments: OHIP-20, SOC-13

Assessment: before treatment and after treatment

Subjects with implants had a significantly higher improvement in OHRQoL versus conventional dentures. There was no significant relationship between OHRQoL and SOC. At both follow-ups, Mean age: 72.1 yrs participants wearing implant(range: 66–88 yrs) supported overdenture 53,6% [IOD] and 53,9% reported significantly better [CD] female total OHIP scores than those wearing conventional dentures. N=135 patients Mean age: 61.6 yrs (range: not reported) 68.1% female

The study observed an improvement in all seven domains of the OHIP-20 after receiving a mandibular threeimplant overdenture.

Measures: OHRQoL, Denture satisfaction Instruments: OHIP-20, DSQ Erkapers et al. To assess satisfaction 201154 after implant treatment in atrophic maxilla

Prospective, multicenter, N=51 patients clinical study Mean age: 65.8 yrs Assessment: prior to (range: 47–83 yrs) treatment and 12 weeks, 52.9% female and 6 and 12 months after treatment

Post-treatment there were significant improvements in total OHIP score and all OHIP subdomain scores on all occasions.

Measures: OHRQoL Instruments: OHIP-49 FernandezEstevan et al. 201577

Assessment of OHRQoL in patients with implant-supported overdentures and conventional complete dentures

Cross-sectional study Assessment: after treatment Measures: OHRQoL Instruments: OHIP-20, OSS.

N=193 (dentate patient group [DP]: n=57; conventional complete denture [CD] group: n=56; implantsupported overdentures [IOD] group: n=80

Patients with implantsupported overdentures has significantly lower OHIP summary scores than patients with conventional complete dentures. Level of impairment in patients with implants was comparable to dentate Mean age: 69.5 yrs [DP controls. and CD] and 69.6 yrs [IOD] 57.2% [DP and CD] and 60.0% [IOD] female

32

Study (year)

Aim

Methods and design

Subjects

Geckili et al. 201155

To assess the impact of two-implant retained overdentures on OHRQoL

Prospective, clinical study

N=78 patients

Assessment: prior to treatment and 6 months after treatment Measures: OHRQoL Instruments: OHIP-14, OHQoL-UK

Geckili et al. 201262

To compare patient satisfaction, quality of life, and bite force with respect to implant support for complete dentures

Cross-sectional study

Following implant treatment Mean age: not provided there was a significant improvement in OHIP-14 total (range: 65–82 yrs) score and all subscale scores. Gender: not provided OHQoL-UK total and all subscales were also significantly improved following implant treatment.

Measures: OHRQoL, satisfaction, bite force

N=100 patients (implant-supported overdenture [IOD] group: n=50; conventional denture [CD] group: n=50)

Instruments: OHIP-14, VAS

Mean age: 67.9 yrs (range: 65–74 yrs)

Assessment: 4 years after treatment

Summary findings

While patients in the implant treatment group were significantly more satisfied than patients with conventional dentures, differences in OHRQoL were only small and not significant.

62.0% [IOD] and 68.0% [CD] female Geckili et al. 201279 and Mumcu et. al. 201278

To assess the influence of masticatory function and type / number of implants on patient satisfaction and quality of life of patients wearing mandibular implant-supported overdentures

Cross-sectional study Assessment: 3 years after treatment Measures: OHRQoL, Satisfaction and Maximum Bite Force Instruments: OHIP -14, VAS

N=62 patients (2 implants with ball: n=14; 2 implants with Locator: n=14; 3 implants with ball: n=12; 3 implants with bar: n=11; 4 implants with bar: n=11

The number of implants or attachment type were not associated with patient satisfaction but with OHRQoL. Lowest OHIP summary scores were observed in patients with 4-implant-supported bars.

Mean age: 64.0 yrs (range: 42–90 yrs) 51.6 % female

Geckili et al. 201580 and Geckili et al. 201581

Gjengedal et al. 201363

To assess the influence of interimplant distance and momentary retention forces on patient satisfaction and QoL in subjects receiving mandibular overdentures supported by two implants

Prospective, clinical study

To compare OHRQoL and HRQoL in edentulous patients who were treated either with a conventional relining of the existing complete denture or by converting it into a implant-retained overdenture

Prospective, RCT

Assessment: after treatment

N=55 patients (ball attachments: n=22, Locator attachments: n=33

Measures: OHRQoL

Mean age: 64.4 yrs (range: not provided)

Instruments: OHIP-14, VAS

56.4% female

Assessment: before treatment, and 3 months and 2 years after treatment Measures: OHRQoL, HRQoL, general wellbeing, coping strategies Instruments: OHIP-20, SF-36, WHO-Five WellBeing Index, BACQ

N=54 patients (relined conventional denture [RCD] group: n=26; implant-retained overdenture [IOD] group: n=28) Mean age: 67 yrs (range: 53–78 yrs) [RCD] and 68 yrs (range: 48–78 yrs) [IOD] 65.4% [RCD] and 64.3% [IOD] female

Longer interimplant distance was associated with better OHRQoL. Furthermore, OHIP scores in the social disability and handicap domains were lower in subjects with higher retention forces.

In edentulous patients dissatisfied with their existing conventional complete dentures, implant support resulted in substantial shortterm and middle-term improvements in OHRQoL whereas conventional relining had no effect on OHRQoL. However, HRQoL, general well-being, and coping strategies were not affected by either treatment option.

33

Study (year)

Aim

Methods and design

Subjects

Summary findings

Harris et al. 201364

Determination of differences in patient satisfaction with implant overdentures compared to conventional complete dentures

Prospective, multicenter RCT

N=122 patients (conventional denture [CD] group: n=62; implant-retained overdenture [IOD] group: n=60)

While in patients dissatisfied with their existing conventional complete dentures the provision with new ones already substantially improved patient satisfaction and OHRQoL, implant treatment led to further improvements in patient perceptions. However, no impact on HRQoL was detected.

Assessment: baseline, 3 months after receiving conventional complete dentures, and additional 3 months with conventional or implantsupported complete dentures

Mean age: 64,4 yrs (range: not provided) 68.0% female

Measures: OHRQoL, denture satisfaction, HRQoL Instruments: OHIP-49, DSQ, SEIQoL Heydecke et al. 200557

Melas et al. 200182

Assessment of the impact of implants on social and sexual activities in subjects with new mandibular conventional complete dentures or 2-implant retained mandibular overdentures

Comparison of OHRQoL between patients treated with implant-stabilized overdentures and conventional dentures

Prospective, RCT Assessment: before treatment and two months after treatment Measures: OHRQoL, social and sexual activities Instruments: OHIP-49, SIQ

Prospective, clinical study Assessment: posttreatment Measures: OHRQoL Instruments: OIDP

N=102 patients (conventional denture [CD] group: n=48; implant-supported overdenture [IOD] group: n=54) Mean age: 51.2 yrs [CD] and 50.8 yrs [IOD] (range 35–65 yrs) 45.8% [CD] and 51.9% [IOD] female

N=83 patients (implant overdenture [IOD] group: n=43; conventional denture [CD] group: n=40) Mean age: 69.6 yrs [CD] and 63.7 yrs [IOD] (range: not provided)

Following treatment, improvements in OHRQoL were reported for each group, but improvement was significantly better for subjects receiving implants versus those receiving conventional dentures. Conventional complete dentures are associated with more negative impacts on leisure and sexual activities than implant overdentures. Compared to conventional dentures patients with implantstabilized overdentures were statistically significantly higher satisfied and experienced less impact on daily life.

52.9% female Mundt et al. 201583

Persic et al. 201672

Assessment of OHRQoL, implant survival and prosthetic aftercare of edentulous people treated with mini dental implants for stabilization of their complete dentures

Retrospective study

N=133 patients

Assessment: retrospective pretreatment (then test) and post treatment

Mean age: 71.2 yrs (range: 48–100 yrs)

Comparison of OHRQoL in patients rehabilitated with three different types of mandibular implant overdentures after at least 3 years in function

Cross-sectional study

OHIP summary scores after treatment were low, indicating high OHRQoL.

59.4% female

Measures: OHRQoL Instruments: OHIP-14

Assessment: 3–5 years after treatment Measures: OHRQoL Instruments: OHIP-14

N=122 patients (4 miniimplants [4MI] group: n=50; 2 implants with locator [2IL] group: n=56; 2 implants with bar [2IB] group: n=16)

Patients with IODs supported by 4 mini-implants had better OHRQoL than those with 2 standard implants and barand locator-retained IODs.

Mean age: 66.7 yrs [4MI], 61.9 yrs [2IL], and 60.8 yrs [2IB] 62.3 % female

34

Study (year)

Aim

Methods and design

Subjects

Preciado et al. To validate QoLIP-10 201365 and to compare OHRQoL in patients with conventional complete dentures, implant-retained overdentures and hybrid implantprostheses

Cross-sectional study

N=150 patients (conventional complete denture group: n=50; implant-retained overdenture group: n=50; hybrid implantprosthesis group: n=50)

Assessment: approximately 1–16 yrs after treatment Measures: OHRQoL Instruments: OHIP-20, QoLIP-10

Summary findings

Overall OHRQoL did not differ significantly between patients with conventional complete dentures, implant-retained overdentures and hybrid implant-prostheses for both instruments OHIP-20 and Mean age: not provided QoLIP-10. (range: 40–90 yrs) 64.0% female

Preciado et al 201366

To validate QoLIP-10 and to assess OHRQoL in patients with various types of screwed implantprostheses

Cross-sectional study Assessment: at least 10 months after treatment Measures: OHRQoL, dental satisfaction Instruments: OHIP-14, QoLIP-10, VAS

Schoen et al. 200859 and Korfage et al. 201158

Sun et al. 201467

To assess impact of mandibular implants on OHRQoL and HRQoL in patients with tooth loss due to head and neck cancer receiving mandibular implantretained overdentures, and to compare effects with respect to radiation

Prospective, clinical study

Evaluation of masticatory efficiency and OHRQoL in patients with implantretained mandibular overdentures

Prospective, clinical study

Assessment: before treatment, 6 weeks, and 1 and 5 years after treatment

N=131 patients (implant-retained overdenture group: n=38, hybrid implantprosthesis group: n=50, implant-supported fixed partial denture group: 43)

While OHRQoL measured with the summary scores of OHIP14 and QoLIP-10 did not differ substantially between patient groups, hybrid prosthesis wearers had lower OHRQoL in some of the subscales, in particular Dental-Facial Aesthetics and Performance of Mean age: not provided the QoLIP-10 and Functional (range: not provided) Limitation of the OHIP-14. 57.3% female N=50 patients Mean age: 61.5 yrs (range 41–81 yrs) 30% female

Measures: OHRQoL, denture satisfaction, HRQoL Instruments: OHIP-49, EORTC QLQ-C30 and H&N35

Assessment: 1 month before treatment, and 6 months after treatment

N=50 patients Mean age: 62 yrs (range: 55–74 yrs) 44.0% female

Measures: OHRQoL, masticatory efficiency Instruments: OHIP-49

Torres et al. 201160

To assess the impact of personality traits on OHRQoL in patients with conventional mandibular overdentures versus implant-supported mandibular overdentures

Cross-sectional study

N=100 subjects Assessment: between 12 (conventional denture and 48 months after [CD] group: n=50, treatment implant-supported overdenture [IOD] Measures: OHRQoL, group: n=50) personality traits Instruments. OHIP-14, NEO-FFI

Mean age: 64.2 yrs [CD] and 61.8 yrs [IOD] (range: not provided)

Implant-retained overdentures were associated with improvements in OHIP scores, which were more pronounced in non-irradiated versus irradiated patients. Posttreatment QoL and OHRQoL were worse in patients who had undergone radiation therapy versus those who had not. In surviving patients, there was no significant change in OHIP scores from 1-year to 5year follow-up. Implant-retained mandibular overdentures significantly improved patients’ OHRQoL. The improvement in OHRQoL was mainly due to a decrease in OHIP scores in the subscale Functional Limitation, which was correlated to improvements in masticatory efficiency. Subjects in the implant group had significantly better OHIP scores in comparison with those with conventional dentures. Personality traits, in particular neuroticism and conscientiousness, were related to OHRQoL in both treatment groups.

52.0% [CD] and 48.0% [IOD] female

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Study (year) Vercruyssen et al. 201484

Aim

Methods and design

Subjects

Summary findings

Comparison of implant and patient outcome of guided and conventional implant placement

Prospective, RCT

N=59 patients

Assessment: after implant placement, prosthesis instalment and 1-year follow-up

Mean age: 58 yrs (range: 31–78 yrs)

For both treatment groups a significant improvement in OHRQoL was observed with no differences between guided or conventional implant placement.

Measures: OHRQoL

52.0% female

Instruments. OHIP-49

Table 3 – Summary of factors potentially affecting implant-related treatment effects as identified in the included studies Factor

Population

Effect

Number of missing and replaced teeth43,44

Partly dentate patients

A larger number of teeth replaced by dental implants is associated with higher OHRQoL improvement.

Location of single implant treatment27

Partly dentate patients

Pre-treatment OHRQoL impairment and treatment-related OHRQoL improvement is highest for missing and replaced anterior teeth and lowest for molars.

Condition of implant site}41

Partly dentate patients

Implants in extraction sockets and in healed alveolar ridges result in similar OHRQoL improvement.

Atrophy of the maxilla and implant position70

Edentulous patients

There is no difference between palatal positioned implants in severely atrophic maxillae and well-centered placed implants in the nonatrophic maxilla in post-treatment satisfaction and OHRQoL.

Biological and clinical characteristics

Technical and treatment characteristics Loading protocol31

Partly dentate patients

OHRQoL improvement might be higher in patients with immediately loaded implants than with conventionally loaded implants.

Implant dimension71.42,85

Partly dentate patients

Implant diameter and implant length is not associated with treatment effects.

Edentulous patients

Treatment with mini-implants might result in higher OHRQoL and satisfaction but considerably lower implant survival rates when compared to standard diameter implants.

Partly dentate patients

Whether implant supported FDP are screwed or cemented does not affect OHRQoL after implant treatment.

Edentulous patients

Overdentures might be associated with lower OHRQoL when retained by locators or bars than with ball ring matrices. Furthermore, implantsupported FDP might be associated with in less psychosocial discomfort and disability than implant-retained overdentures.

Retention51,72,86.78,79

Personality and psychosocial characteristics Neuroticism24,36,37,60

Partly dentate and edentulous patients

Higher levels of neuroticism are associated with less satisfactory effects of implant treatment in terms of OHRQoL.

Sense of coherence (SOC)53,69

Edentulous patients

SOC is not associated with post-treatment OHRQoL.

OHRQoL before treatment48

Edentulous patients

Only if OHRQoL is highly impaired at baseline, implant-support is associated with higher treatment-induced OHRQoL improvement than without implants.

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Patient’s request47

Edentulous patients

Only if patients request implants, implant-support is associated with higher treatment-induced OHRQoL improvement than without implants.

Edentulous patients

Customized dietary advices have no meaningful effect on OHRQoL.

Behavior Dietary advices52

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