- Email: [email protected]
The Use of Mandibular Implant-Retained Overdentures Improve Patient Satisfaction and Quality of Life
Previously Published
Review analysis & evaluation
The Use of Mandibular Implant-retained Overdentures Improve Patient Satisfaction and Quality of Life Article Title and Bibliographic Information
Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Emami E, Heydecke G, Rompre PH, de Grandmont P, Feine JS. Clin Oral Implants Res 2009;20(6):533-44. Reviewer
J. Mark Thomason, BDS, PhD, FDS, RCS(Ed) Purpose/Question
Do edentulous individuals who are provided with mandibular conventional or implant-retained overdentures rate their general satisfaction, oral or general health–related quality of life differently? Source of Funding
The authors reported that no external funding sources directly supported this study. Type of Study Design
Systematic review with metaanalysis of data. Level of Evidence
level 2
Good-quality, patientoriented evidence
Strength of Recommendation Grade
A
Consistent, good-quality patientoriented evidence
Reviewer: J. Mark Thomason, BDS, PhD, FDS, RCS(Ed), Professor of Prosthodontics and Oral Rehabilitation, Director of Clinical Studies, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom, E‑mail: j.m.thomason@ ncl.ac.uk Originally Published in: J Evid Base Dent Pract 2010;10:61-63 1532-3382/$36.00 © 2010 Elsevier Inc. All rights reserved. doi: 10.1016/j.jebdp.2009.11.022
Volume 12, Supplement 1
SUMMARY
Selection Criteria This study comprises meta-analyses of studies examining the effect of treatment of edentulism with implant-retained mandibular overdentures. Initially 2262 nonduplicated articles were identified from the database searches, of which 37 were eligible for full-text searching. Twenty-seven were excluded because they failed to meet the inclusion criteria, their populations and outcomes overlapped, or their outcomes were outside the remit of the review. A total of 10 manuscripts on 7 randomized controlled trials were included in the meta-analysis. The sample sizes in these trials varied from 60 to 157 participants. The total number of different subjects included in the studies considered was 750. Some of the published papers included the same study populations but with different outcome measures, for example Awad et al1 and Thomason et al2 (oral health–related quality of life at 2 months and general satisfaction at 6 months, respectively). Study populations that appeared in more than 1 publication were included only once in the meta-analysis using the more informative publication for that outcome. The age range of those involved in the studies ranged from 35 to 80 years, and all patients wore conventional maxillary complete dentures and either mandibular implant-retained or conventional complete dentures. Outcomes were included with a follow-up period of at least 2 months.
Key Study Factor Key study factors were the treatment with an implant-retained mandibular overdenture of edentulous patients who had previously been treated with conventional complete dentures.
Main Outcome Measure The primary outcomes were general satisfaction, oral health quality of life (QOL), and general health QOL measures. These patient-centred measures were used to assess the efficacy of the treatment provided. Outcomes of the meta-analysis are expressed in terms of effect size (ES).
Main Results Ten publications of 7 randomized controlled trials were identified, and 8 of these publications were used in the meta-analysis. For the effect of treatment on general patient satisfaction, from the 10 publications 6 studies with a population of 588 participants (n = 322 implant overdentures; n = 266 conventional dentures) were used. General satisfaction was expressed by the participants using a 100-mm visual analog scale or Likert-type response scale. The pooled ES was 0.80 (z = 3.56, 95% confidence interval [CI] 0.36-1.24, P = .0004) in favor of the implant overdenture. The standardized mean differences were positive in all of the studies. The P value for heterogeneity (χ2 = 31.63, df = 5) was P less than .00001 and l = 84%. 2
182
Journal of evidence-based dental practice Special Issue—Periodontal and Implant Treatment
For the effect of mandibular prosthesis on oral health-related QOL, the meta-analysis included only studies using the Oral Health Impact Factor (OHIP) as the measurement instrument. A total of 280 participants were therefore included in the analysis (n = 146 implant over-dentures; n = 134 conventional dentures). For the 3 pooled trials the ES was −0.41(z = 131, 95% CI −1.02 to 0.20, P = .19). Significant heterogeneity was again observed. The P value for heterogeneity (c 2 = 11.53, df=2) was P equals .003 and l2 equals 83%. In 2 of the 3 trials the 95% CI did not include an ES of zero. When the analysis was restricted to studies including populations that were recruited from the general population recruited via advertisement, the pooled ES values declined from −0.41 to −0.71 (z = 4.37, 95% CI −1.03 to −0.39, P < .0001), the −ve value for their ES were consistent with a significantly positive effect in favor of the implant overdenture treatment.
for both satisfaction outcomes and for oral health–related QOL. The potential differences in the patient characteristics are offered as one potential explanatory factor (eg, diabetic or maladaptive patients). Equally, they point out that when the subgroup analysis for general satisfaction was confined to recruitment of patients with severely impaired conditions, the effect size values (ES) increased but the statistical heterogeneity remained. Subgroup analysis is potentially interesting, as it may help us (long term) to understand and identify target groups that may benefit most from the treatment; but caution is rightly expressed when drawing conclusions from this small number of trials with many clinical differences. Currently, as the authors point out, the potential sources of heterogeneity could (perhaps) best be considered as hypotheses for further studies.3 Overall, the review strengthens the arguments presented in the McGill4 and the York5 consensus statements proposing that a 2-implant–supported mandibular over-denture should be the minimum offered to edentulous patients as a first choice of treatment. Conventional dentures as we know them have been the traditional standard of care for edentulous patients for more than a century, as there has been no practical alternative. It is, however, well recognized that many patients struggle to use these prostheses. The mobility and discomfort, especially associated with the mandibular denture, have been linked to social, psychological, and functional disabilities. The advent of osseointegrated implants has opened up a series of alternative treatments, of which the implant overdenture is probably the best researched in terms of patient-centered outcomes.The current study outlines the fact that the treatment is associated with a more positive outcome than the previous standard of care, although the magnitude of the effect still remains to be clarified. To be assured, rather than to strongly suspect, that the benefits of this treatment is large enough for all (members of the profession and funders) to accept it as the first treatment option for edentulous patients will require further data to strengthen any analysis. The authors call for ‘‘additional metaanalyses on well-conducted randomized controlled trials that include relevant economic assessments.’ ’ This is undoubtedly appropriate, although we should also remember that we currently have more patient-centered outcome data for implant overdentures than for any other form of prosthodontic/restorative rehabilitation procedure.6
For the effect of treatment on perceived general health, only 1 article was found that used a general instrument to measure this—the authors had used the SF-36 and found no difference between groups on any of the subscales— as no other study used a similar scoring method no further processing of the data was undertaken.
Conclusions The analyses illustrate that patient general satisfaction and oral health–related QOL are greater with mandibular im plant-retained overdentures than conventional dentures, but the magnitude of these effects remain uncertain, and heterogeneity of outcomes was observed. The review sheds no new light on the effect of the treatment on general health related QOL.
COMMENTARY AND ANALYSIS This article draws together data from randomized studies looking at the effect of treatment provided to patients with established edentulism who require replacement prostheses. The meta-analyses examine data from 6 studies using a patient’s general satisfaction as an outcome (and subgroup analysis), and then 3 studies (subanalysis on 2 of these) using oral health–related QOL as the outcome. The review clearly establishes that implant-retained mandibular overdentures have more positive outcomes in terms of general satisfaction and oral health–related QOL than conventional dentures, although the magnitude of the effects remains uncertain. As such, the results are not surprising, but extremely welcome to those working in this area and with these patients. To undertake meaningful meta-analyses such as this one requires studies reporting data in comparable formats so the observation by the authors that further studies reporting results using the CONSORT guidelines are required is equally unsurprising.
REFERENCES
Part of the difficulty inestablishing the magnitude ofthe effects is illustrated by the heterogeneity identified by the authors
183
1.
Awad MA, Lund JP, Shapiro SH, Locker D, Klemetti E, Chehade A, et al. Oral health status and treatment satisfaction with mandibular implant overdentures and conventional dentures: a randomized clinical trial in a senior population. Int J Prosthodont 2003;16(4):390-6.
2.
Thomason JM, Lund JP, Chehade A, Feine JS. Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. Int J Prosthodont 2003;16(5):467-73.
September 2012
Journal of evidence-based dental practice Special Issue—Periodontal and Implant Treatment 3.
Thompson SG. Why sources of heterogeneity in meta-analysis should be investigated. BMJ 1994;309(6965):1351-5.
4.
Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill Consensus Statement on Overdentures. Montreal, Quebec, Canada. May 24-25, 2002. Int J Prosthodont 2002;15(4):413-4.
5.
Thomason JM, Feine J, Exley C, Moynihan P, Müller F, Naert I, et al. Mandibular two implant-supported overdentures as the first choice
Volume 12, Supplement 1
standard of care for edentulous patients—the York Consensus Statement. Br Dent J 2009;207:185-6. 6.
184
Thomason JM, Heydecke G, Feine JS, Ellis JS. How do patients perceive the benefit of reconstructive dentistry with regard to oral health-related quality of life and patient satisfaction? A systematic review. Clin Oral Implants Res 2007;18(Suppl 3):168-88. Erratum in: Clin Oral Implants Res 2008;19(3):326-8.
Review analysis & evaluation
The Use of Mandibular Implant-retained Overdentures Improve Patient Satisfaction and Quality of Life Article Title and Bibliographic Information
Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials. Emami E, Heydecke G, Rompre PH, de Grandmont P, Feine JS. Clin Oral Implants Res 2009;20(6):533-44. Reviewer
J. Mark Thomason, BDS, PhD, FDS, RCS(Ed) Purpose/Question
Do edentulous individuals who are provided with mandibular conventional or implant-retained overdentures rate their general satisfaction, oral or general health–related quality of life differently? Source of Funding
The authors reported that no external funding sources directly supported this study. Type of Study Design
Systematic review with metaanalysis of data. Level of Evidence
level 2
Good-quality, patientoriented evidence
Strength of Recommendation Grade
A
Consistent, good-quality patientoriented evidence
Reviewer: J. Mark Thomason, BDS, PhD, FDS, RCS(Ed), Professor of Prosthodontics and Oral Rehabilitation, Director of Clinical Studies, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom, E‑mail: j.m.thomason@ ncl.ac.uk Originally Published in: J Evid Base Dent Pract 2010;10:61-63 1532-3382/$36.00 © 2010 Elsevier Inc. All rights reserved. doi: 10.1016/j.jebdp.2009.11.022
Volume 12, Supplement 1
SUMMARY
Selection Criteria This study comprises meta-analyses of studies examining the effect of treatment of edentulism with implant-retained mandibular overdentures. Initially 2262 nonduplicated articles were identified from the database searches, of which 37 were eligible for full-text searching. Twenty-seven were excluded because they failed to meet the inclusion criteria, their populations and outcomes overlapped, or their outcomes were outside the remit of the review. A total of 10 manuscripts on 7 randomized controlled trials were included in the meta-analysis. The sample sizes in these trials varied from 60 to 157 participants. The total number of different subjects included in the studies considered was 750. Some of the published papers included the same study populations but with different outcome measures, for example Awad et al1 and Thomason et al2 (oral health–related quality of life at 2 months and general satisfaction at 6 months, respectively). Study populations that appeared in more than 1 publication were included only once in the meta-analysis using the more informative publication for that outcome. The age range of those involved in the studies ranged from 35 to 80 years, and all patients wore conventional maxillary complete dentures and either mandibular implant-retained or conventional complete dentures. Outcomes were included with a follow-up period of at least 2 months.
Key Study Factor Key study factors were the treatment with an implant-retained mandibular overdenture of edentulous patients who had previously been treated with conventional complete dentures.
Main Outcome Measure The primary outcomes were general satisfaction, oral health quality of life (QOL), and general health QOL measures. These patient-centred measures were used to assess the efficacy of the treatment provided. Outcomes of the meta-analysis are expressed in terms of effect size (ES).
Main Results Ten publications of 7 randomized controlled trials were identified, and 8 of these publications were used in the meta-analysis. For the effect of treatment on general patient satisfaction, from the 10 publications 6 studies with a population of 588 participants (n = 322 implant overdentures; n = 266 conventional dentures) were used. General satisfaction was expressed by the participants using a 100-mm visual analog scale or Likert-type response scale. The pooled ES was 0.80 (z = 3.56, 95% confidence interval [CI] 0.36-1.24, P = .0004) in favor of the implant overdenture. The standardized mean differences were positive in all of the studies. The P value for heterogeneity (χ2 = 31.63, df = 5) was P less than .00001 and l = 84%. 2
182
Journal of evidence-based dental practice Special Issue—Periodontal and Implant Treatment
For the effect of mandibular prosthesis on oral health-related QOL, the meta-analysis included only studies using the Oral Health Impact Factor (OHIP) as the measurement instrument. A total of 280 participants were therefore included in the analysis (n = 146 implant over-dentures; n = 134 conventional dentures). For the 3 pooled trials the ES was −0.41(z = 131, 95% CI −1.02 to 0.20, P = .19). Significant heterogeneity was again observed. The P value for heterogeneity (c 2 = 11.53, df=2) was P equals .003 and l2 equals 83%. In 2 of the 3 trials the 95% CI did not include an ES of zero. When the analysis was restricted to studies including populations that were recruited from the general population recruited via advertisement, the pooled ES values declined from −0.41 to −0.71 (z = 4.37, 95% CI −1.03 to −0.39, P < .0001), the −ve value for their ES were consistent with a significantly positive effect in favor of the implant overdenture treatment.
for both satisfaction outcomes and for oral health–related QOL. The potential differences in the patient characteristics are offered as one potential explanatory factor (eg, diabetic or maladaptive patients). Equally, they point out that when the subgroup analysis for general satisfaction was confined to recruitment of patients with severely impaired conditions, the effect size values (ES) increased but the statistical heterogeneity remained. Subgroup analysis is potentially interesting, as it may help us (long term) to understand and identify target groups that may benefit most from the treatment; but caution is rightly expressed when drawing conclusions from this small number of trials with many clinical differences. Currently, as the authors point out, the potential sources of heterogeneity could (perhaps) best be considered as hypotheses for further studies.3 Overall, the review strengthens the arguments presented in the McGill4 and the York5 consensus statements proposing that a 2-implant–supported mandibular over-denture should be the minimum offered to edentulous patients as a first choice of treatment. Conventional dentures as we know them have been the traditional standard of care for edentulous patients for more than a century, as there has been no practical alternative. It is, however, well recognized that many patients struggle to use these prostheses. The mobility and discomfort, especially associated with the mandibular denture, have been linked to social, psychological, and functional disabilities. The advent of osseointegrated implants has opened up a series of alternative treatments, of which the implant overdenture is probably the best researched in terms of patient-centered outcomes.The current study outlines the fact that the treatment is associated with a more positive outcome than the previous standard of care, although the magnitude of the effect still remains to be clarified. To be assured, rather than to strongly suspect, that the benefits of this treatment is large enough for all (members of the profession and funders) to accept it as the first treatment option for edentulous patients will require further data to strengthen any analysis. The authors call for ‘‘additional metaanalyses on well-conducted randomized controlled trials that include relevant economic assessments.’ ’ This is undoubtedly appropriate, although we should also remember that we currently have more patient-centered outcome data for implant overdentures than for any other form of prosthodontic/restorative rehabilitation procedure.6
For the effect of treatment on perceived general health, only 1 article was found that used a general instrument to measure this—the authors had used the SF-36 and found no difference between groups on any of the subscales— as no other study used a similar scoring method no further processing of the data was undertaken.
Conclusions The analyses illustrate that patient general satisfaction and oral health–related QOL are greater with mandibular im plant-retained overdentures than conventional dentures, but the magnitude of these effects remain uncertain, and heterogeneity of outcomes was observed. The review sheds no new light on the effect of the treatment on general health related QOL.
COMMENTARY AND ANALYSIS This article draws together data from randomized studies looking at the effect of treatment provided to patients with established edentulism who require replacement prostheses. The meta-analyses examine data from 6 studies using a patient’s general satisfaction as an outcome (and subgroup analysis), and then 3 studies (subanalysis on 2 of these) using oral health–related QOL as the outcome. The review clearly establishes that implant-retained mandibular overdentures have more positive outcomes in terms of general satisfaction and oral health–related QOL than conventional dentures, although the magnitude of the effects remains uncertain. As such, the results are not surprising, but extremely welcome to those working in this area and with these patients. To undertake meaningful meta-analyses such as this one requires studies reporting data in comparable formats so the observation by the authors that further studies reporting results using the CONSORT guidelines are required is equally unsurprising.
REFERENCES
Part of the difficulty inestablishing the magnitude ofthe effects is illustrated by the heterogeneity identified by the authors
183
1.
Awad MA, Lund JP, Shapiro SH, Locker D, Klemetti E, Chehade A, et al. Oral health status and treatment satisfaction with mandibular implant overdentures and conventional dentures: a randomized clinical trial in a senior population. Int J Prosthodont 2003;16(4):390-6.
2.
Thomason JM, Lund JP, Chehade A, Feine JS. Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. Int J Prosthodont 2003;16(5):467-73.
September 2012
Journal of evidence-based dental practice Special Issue—Periodontal and Implant Treatment 3.
Thompson SG. Why sources of heterogeneity in meta-analysis should be investigated. BMJ 1994;309(6965):1351-5.
4.
Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill Consensus Statement on Overdentures. Montreal, Quebec, Canada. May 24-25, 2002. Int J Prosthodont 2002;15(4):413-4.
5.
Thomason JM, Feine J, Exley C, Moynihan P, Müller F, Naert I, et al. Mandibular two implant-supported overdentures as the first choice
Volume 12, Supplement 1
standard of care for edentulous patients—the York Consensus Statement. Br Dent J 2009;207:185-6. 6.
184
Thomason JM, Heydecke G, Feine JS, Ellis JS. How do patients perceive the benefit of reconstructive dentistry with regard to oral health-related quality of life and patient satisfaction? A systematic review. Clin Oral Implants Res 2007;18(Suppl 3):168-88. Erratum in: Clin Oral Implants Res 2008;19(3):326-8.