WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

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Treatment Outcomes with Removable Partial Dentures: A Comparison Between Patient and Prosthodontist Assessments

Dubravka Knezovic Zlataric , DDS, MSDa Asja Celebic , DDS, MSD, PhDb

Purpose: This article presents the results from a survey of patients degree of satisfaction with their removable partial dentures (RPD) and the comparison between patient and prosthodontist assessments. Materials and Methods: A total of 165 experienced RPD wearers filled in a questionnaire and graded their RPDs depending on their level of satisfaction. A scale ranging from 1 to 5 was used to assess general satisfaction with RPDs and to assess their esthetics, retention, and hygiene. A specialist in prosthodontics assessed the same prostheses using the same scale, not knowing the patients opinion. Results: The patients assessments were high, and more than half of them graded their dentures as excellent. On average, all variables were assessed higher by the patients than by the prosthodontist (P < .001). For the patients who gave the worst grades to their dentures, the grades were lower than the prosthodontists (P < .001), while the satisfied patients graded their dentures much better than did the prosthodontist (P < .001). Conclusion: On average, patient assessment of the treatment outcomes with RPDs was less critical than prosthodontist assessment. However, the few dissatisfied patients assessed their dentures worse than did the prosthodontist. Int J Prosthodont 2001;14:423426.

he majority of patients are satisfied with their removable partial dentures (RPD).1 However, even if RPDs are constructed according to all accepted criteria, some patients will still be dissatisfied. Satisfaction with RPDs seems to have a multicausal character.2 In addition to the factors directly related to the functioning of dentures, patient-related factors influence the final result. Satisfaction with RPDs relates in some patients primarily to comfort and the ability to masticate,3 but esthetics and retention also seem to be important.4 Besides the clinicians skill and the quality of dentures, the following factors related to the patient are very important to final satisfaction with RPDs: personality, attitude toward the dentures, prior RPD experience, and motivation for wearing a denture.5,6 The
a Junior

Researcher, Department of Prosthodontics, School of Dental Medicine, University of Zagreb, Croatia. b Associate Professor, Department of Prosthodontics, School of Dental Medicine, University of Zagreb, Croatia. Reprint requests: Dr Dubravka Knezovic Zlataric , Department of Prosthodontics, School of Dental Medicine, University of Zagreb, Gundulic eva 5, 10000 Zagreb, Croatia. Fax: + 38514802159. e-mail: dkz@email.hinet.hr

patients expectations of the dentures are related to satisfaction, which makes later adjustment to the dentures easier, regardless of the oral conditions.7 The most common reasons for patient dissatisfaction with RPDs have already been studied.8,9 They are the condition, number, and alignment of the abutment teeth; the gingival, periodontal, and mucosal tissue health; the type of the construction and denture support; and the material and denture base shape (the type of the major connectors). According to the results of recent studies, the most frequent areas of dissatisfaction are fit (34%), eating-chewing (30%), natural tooth problems (26%), mouth cleanliness (20%), speech (18%), appearance (18%), denture cleanliness (15%), and odor (13%).5,6 The success of RPD treatment, however, is often judged differently by clinicians and patients.10 Prosthodontists consider their dentures to be successful if they meet certain technical standards,11 whereas patients evaluate them from the viewpoint of their personal satisfaction.12 Knowledge about patient satisfaction with the treatment outcomes of their RPDs would be helpful to both clinicians and patients as they decide on prosthodontic treatment. The purpose of the present

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study was to determine the degree of patient satisfaction with their RPDs and to compare patient and prosthodontist assessments of treatment outcome.

Results
The great majority of the patients were very satisfied with the treatment outcome, and the median value was 5 for all assessments. The median for the prosthodontists evaluation of the RPDs was lower; for the general assessment, esthetics, and hygiene it was 4, and for the retention it was 3. The distribution of patient and prosthodontist general assessments for the maxillary and mandibular RPDs is shown in Fig 1. The distribution of the grades was different from the normal distribution (one-sample KolmogorovSmirnov test, P < .001). The distribution of patient grades in this study was completely skewed toward the highest scores. The distribution of prosthodontist grades was also skewed toward the highest scores, but not as much as the patients grades. More than half of the patients assessed all variables describing their satisfaction with the RPDs as the best (grade 5). The highest percentage of the patients best scores (grade 5) was assigned to the esthetics of the maxillary and mandibular RPDs (80% and 76%, respectively). The parameter with the highest percentage of the lowest scores (grade 1) was the patients general satisfaction with their mandibular RPDs (2%). According to this study, the percentage of completely dissatisfied (grade 1) patients was 2% for the mandibular and 1% for the maxillary RPDs. The percentage of hardly satisfied patients was 2% for the mandibular RPDs, and none of the patients were hardly satisfied with their maxillary RPDs. The prosthodontist listed 30% of the RPDs in the best category, which was significantly lower than the patients listing (74%; P < .001), while 57% of the RPDs were given grade 4. Patient assessments were higher than those of the prosthodontist for all variables (P < .001).

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Materials and Methods

A total of 165 patients with RPDs made by different clinicians at the Department of Removable Prosthodontics, School of Dental Medicine, University of Zagreb, Croatia took part in this study. The patients were chosen at random from the files of the department. The patients had been wearing the existing RPDs for different periods ranging from 1 to 10 years. There were 59 men and 105 women aged between 38 and 87 years. The examined patients had 113 maxillary and 130 mandibular RPDs. The RPDs were of different Kennedy classifications and denture support modes. (The most frequent was Kennedy Class I and tooth-retained dentures, at 81%). In 48% of the dentures, at least one of the anterior teeth had been replaced. A questionnaire divided into two parts was devised for the purposes of the study, and it was completed by both the patients and the prosthodontist independently. To ensure an objective assessment, the patients were attributed an identifying number when responding to the questionnaire (on paper). The prosthodontist assessing the dentures independently was referring only to those identifying numbers, not to the patients names, for the same reasons of objectivity. In the first part of the questionnaire, the patients graded the RPDs depending on the level of their satisfaction, using a scale from 1 to 5. The 1 to 5 scale is a common grading scale in the Croatian educational system (1 = unsatisfactory, 2 = hardly satisfactory, 3 = satisfactory on average, 4 = very satisfactory, 5 = excellent). The patients first graded their dentures in general, and then they gave separate grades on the retention, esthetics, and hygiene of their dentures (their opinion on how clean they thought they kept their RPDs). In the second part of the questionnaire, a trained prosthodontist evaluated the dentures, also by using the scale from 1 to 5 and without any idea about the patients assessments. Prior to the assessment, three different specialists in prosthodontics separately evaluated 10 different RPDs, and a Kappa test revealed sufficient consistency between them (from .72 to .89 for the different parameters assessed), but it was decided that only one of them should evaluate all patients. A descriptive statistical analysis (SPSS 10.0 for Windows) was made. The homogeneity of the population was tested using the one-sample KolmogorovSmirnov test. The difference between patient and the prosthodontist assessments was tested by the Wilcoxon test. Differences in P values that were < .001 were considered significant.

Discussion
There are many factors dependent on the patient, as well as on the clinician, that could have an influence on patients satisfaction with their RPDs.13,14 Aside from psychologic factors, other factors that depend upon the patient are quality of the denture-supporting area, quality of the oral mucosa, influence of the surrounding muscles on the denture flanges, viscosity of saliva, patients age and ability to get used to the denture, state of the abutments, condition of the other teeth in the mouth, relation between the horizontal and vertical dimensions of occlusion, hygiene habits, diet, presence of chronic diseases, position of the patients teeth in the mouth, and quality of the removable appliance.1518

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Patient and Prosthodontist Assessments of RPDs

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Patient assessment, maxillary RPD Patient assessment, mandibular RPD Prosthodontist assessment, maxillary RPD Prosthodontist assessment, mandibular RPD 70 60 50 40 30 20 10 0 Percentage 80

3 Grade

Fig 1

Patients and prosthodontists general assessment of RPDs.

According to the results of this study, it is clear that the distribution curve showing the patient assessments depending on the level of satisfaction with their RPDs is skewed toward the highest score area, ie, the majority of the patients (more than 60%) gave the highest grade to their dentures (Fig 1). These facts point out that most patients are completely satisfied with their therapy outcomes. Although it was reported elsewhere that the presence of anterior teeth in an RPD could influence patients degree of satisfaction,6 this was not true in our previous study.19 For that reason, it was decided that patients with anterior teeth replaced in the RPDs should not be treated separately in the present study. The results of this study considering patient satisfaction are even better than the results from some other studies dealing with complete dentures, overdentures, implant-supported dentures, RPDs, and fixed partial dentures, in which the percentage of dissatisfied patients varied between 20% and 35%.3,2030 Although it is not completely justified to compare patient acceptance of complete dentures and RPDs, we would like to underline that patients general satisfaction with their RPDs registered in this study was better than patients general satisfaction with their complete dentures in the Croatian adult population. Considering the 54% of the patients completely satisfied with the complete dentures, 7% completely dissatisfied, and 11% hardly satisfied,27,28 there are fewer dissatisfied patients with RPDs. Better satisfaction with the RPDs in comparison to the complete dentures could be ascribed to the clasps and other

retentive elements, indirect and direct retainers used in the construction of partial dentures to improve retention and stability, or even partially edentulous patients better sense of chewing force because of the mechanoreceptors in the periodontal ligament of the remaining teeth.29 The opinion of the RPD treatment outcomes was significantly different between the patients and the assessing prosthodontist. Generally, when compared to the most satisfied patients, the prosthodontist evaluated the RPD with lower grades; compared with the least satisfied patients, the prosthodontist graded the RPD with higher grades. When the patient was satisfied, he or she graded the RPD as the best, probably without any margin of criticism, a phenomenon that held true for the worst grades. Almost the same results appeared in a study comparing the esthetic outcome of implantsupported single-tooth replacement assessed by patients and prosthodontists. The appreciation of esthetics was rated higher by patients than prosthodontists.30 These facts point out that subjective patient factors, such as psychologic factors, attitude toward the RPD, expectations, etc, play a role in the final result of the therapy; we can suppose that the clinicians assessment is more objective, as it relies on technical denture standards and clinical demands in the mouth.

Conclusion
The results reflecting patient satisfaction with the treatment outcomes of their RPDs could be helpful to

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both clinicians and patients in treatment planning. Obviously, the clinician should give a thorough explanation of what can be expected from the RPD and its esthetic and functional limitations (chewing, speech) to avoid unrealistic expectations on the part of some patients. The patients were mostly satisfied with their partial dentures. Only 2% of the patients were completely dissatisfied with their mandibular RPDs, and 1% were completely dissatisfied with their maxillary RPDs. A significant difference was registered between prosthodontist and patient assessments of the quality of the RPDs (P < .001). Compared to the most satisfied patients, the prosthodontist assessed the RPDs with lower grades, whereas the few dissatisfied patients assessed their dentures worse than did the prosthodontist.

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References
1. Watson CL, Reeve PE, Barnes E, Lane AE, Bates JF. The role of personality in the management of partial dentures. J Oral Rehabil 1986;13:8391. 2. Van Waas M, Meeuwissen J, Meeuwissen R, Kyser A, Kalk W, vant Hof M. Relationship between wearing a removable partial denture and satisfaction in the elderly. Community Dent Oral Epidemiol 1994;22:315318. 3. Reifel NM, Rana H, Marcus M. Consumer satisfaction. Adv Dent Res 1997;11:281290. 4. Hoad-Reddick G, Grant AA. Prosthetic status: The formation of a schedule. J Prosthet Dent 1988;59:105110. 5. Frank RP, Brudvik JS, Leroux B, Milgrom P, Hawkins N. Relationship between the standards of removable partial denture construction, clinical acceptability, and patient satisfaction. J Prosthet Dent 2000;83:521527. 6. Frank RP, Milgrom P, Leroux BG, Hawkins NR. Treatment outcomes with mandibular removable partial dentures: A populationbased study of patient satisfaction. J Prosthet Dent 1998;80:3645. 7. Merelie DL, Heyman B. Dental needs of the elderly in residental care in Newcastle-upon-Tyne and the role of formal carers. Community Dent Oral Epidemiol 1992;20:106111. 8. Jokovic A, Locker D. Dissatisfaction with oral health status in an older adult population. J Public Health Dent 1997;57:4047. 9. Wakabayashi N, Yatabe M, Ai M, Sato M, Nakamura K. The influence of some demographic and clinical variables on psychosomatic traits of patients requesting replacement removable partial dentures. J Oral Rehabil 1998;25:507512. 10. Kay EJ. Patient needsMore than meets the eye. Br Dent J 1993;20:212214. 11. Hakestam U, Karlsson T, Soderfeldt B, Ryden O, Glantz P. Does the quality of advanced prosthetic dentistry determine patient satisfaction? Acta Odontol Scand 1997;55:365371.

12. OBoyle KH, Gallagher FD, OSullivan M, McDevitt WE. The effect of posture change on the position of the skin marks for the transverse horizontal axis. J Prosthet Dent 1996;75:545551. 13. Burns DR, Unger JW, Elswick RK Jr, Beck DA. Prospective clinical evaluation of mandibular implant overdentures: Part I Retention, stability, tissue response. J Prosthet Dent 1995;73: 354363. 14. Burns DR, Unger JW, Elswick RK Jr, Giglio JA. Prospective clinical evaluation of mandibular implant overdentures: Part IIPatient satisfaction and preference. J Prosthet Dent 1995;73:364369. 15. Cowan RD, Gilbert JA, Elledge DA, McGlynn FD. Patient use of removable partial dentures: Two- and four-year telephone interviews. J Prosthet Dent 1991;65:668670. 16. Wong MM, Ettinger R, Barsby MJ. An evaluation of removable partial dentures: A retrospective study. Iowa Dent J 1995;81:1316. 17. Steele JG, Ayatollahi SM, Walls AW, Murray JJ. Clinical factors related to reported satisfaction with oral function amongst dentate older adults in England. Community Dent Oral Epidemiol 1997;25:143149. 18. Petridis H, Hempton TJ. Periodontal considerations in removable partial denture treatment: A review of the literature. Int J Prosthodont 2001;14:164172. elic elebic 19. Knezovic Zlataric D, C A, Valentic -Peruzovic M, C R, Filipovic -Zore I, Bauc ic M. The satisfaction with removable partial denture therapy in the Croatian adult population. Coll Antorpol 2000;24:485493. 20. Windchy AM, Morris JC. An alternative treatment with the overlay removable partial dentures: A clinical report. J Prosthet Dent 1998;79:249253. 21. Budtz-Jrgensen E, Bochet G. Alternate framework designs for removable partial dentures. J Prosthet Dent 1998;80:5866. 22. de Grandmont P, Feine JS, Tache R, et al. Within-subject comparisons of implant-supported mandibular prostheses: Psychometric evaluation. J Dent Res 1994;73:10961108. 23. Libby G, Arcuri MR, LaVelle WE, Hebl L. Longevity of fixed partial dentures. J Prosthet Dent 1997;78:127131. 24. Berg E. Acceptance of full dentures. Int Dent J 1993;43:299306. 25. Jeganathan S, Payne JA. Common faults in complete dentures: A review. Quintessence Int 1993;24:483487. 26. Lamoureux J, Tache R, de Grandmont P. Patient evaluation of treatment success as related to dentures. Int J Prosthodont 1999;12: 272278. 27. Baer MI, Elias SA, Reynolds MA. The use of psyhological measures in predicting patient satisfaction with complete dentures. Int J Prosthodont 1992;5:221226. elebic 28. C A, Valentic -Peruzovic M, Stipetic J, Zrna M, Kuna T, Delic Z. Patients satisfaction with full dentures of varying age. Acta Stomatol Croat 1999;33:421429. elebic 29. C A, Valentic -Peruzovic M, Stipetic J, Delic Z, Stanic ic T, Ibrahimagic L. The patients and the therapists evaluation of complete denture therapy. Coll Antropol (Suppl) 2000;24:7178. 30. Chang M, dman PA, Wennstrm JL, Andersson B. Esthetic outcome of implant-supported single-tooth replacement assessed by the patient and the prosthodontist. Int J Prosthodont 1999;12: 335341.

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