CompleteDentures

The value

of subjective

evaluation

in clinical

research

Jack H. Rayson, D.D.S.,* Arthur 0. Rahn, D.D.S.,** Charles W. Ellinger, D.D.S., KS.,*** Robert C. Wesley, D.M.D.,**** Quentin Z. Frazier, M.S., Davis Henderson, D.D.S.,***** D&D.,**** Marvin R. lutes, D.M.D., **** and John V. Haley, Ph.D.****** University of Kentucky, College of Dentistry, Lexington, Ky.

ubjective evaluation plays a major role in clinical dentistry, academic dentistry, and dental research. Objective data collected by sophisticated means is often interpreted subjectively, and the real value of subjective evaluation is often questioned. The educational background, experience, bias, and personal feelings of the evaluator may influence the results. This study was designed to answer the following questions: ( 1) Can three qualified dentists each using the same criteria for evaluation arrive independently at the same subjective evaluation ? (2) Can these dentists evaluate one variable more accurately than another? (3) Can a new complete denture be evaluated with more accuracy than one which has been in service? PROCEDURE FOR EVALUATION

Fifty-two edentulous patients were selected at random from the genera1 population. They had been edentulous for at least one year. Fifty-one of the patients wore complete dentures. One patient had no restoration. The patients were divided into two groups, and these were designated as Group I and Group II. Each patient was assigned to one of five dentists participating in the project for the construction of new dentures. Bilateral balanced occlusions in eccentric positions were developed for the Group II patients. No effort was made
*Associate Professor and Chairman, versity School of Dentistry. **Associate Professor and Chairman, Georgia School of Dentistry. ***Associate ****Assistant Professor and Director Professor, Department Department Department of Complete of Prosthodontics, of Prosthodontics, Dentures. Louisiana Medical State UniCollege of

of Prosthodontics. Science,

*****Associate Professor and Chairman, Department of Prosthodontics. ******Associate Professor, Psychology and Statistics, Department of Behavioral University of Kentucky College of Medicine.

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RATING LEGEND 1. Centric Relation - Centric

FOR SUBJECTIVE Occlusion

EVALUATION

4. - Centric relation and centric occlusion coincide. 3. - Slight variation (up to l/2 m) between centric relation and centric occlusion. 2. - Variation (2/3 - 1. 5mm) between centric relation and centric occlusion. 1. - A gross error between centric relation and centric occlusion which can be corrected only by resetting the teeth. 2. Retention 4. 3. 2. 1. 3. (Denture to soft tissue relationship)

Extremely difficult to break border seal. Moderately difficult to break border seal. Slight resistance before border seal breaks. No border seal. (Denture to bone foundation relationship) of strong direct or rotary

Stability

4. - Little or no movement on application force. 3. - Little or no movement on application lodged when a strong direct force 2. - Considerable movement on application dislodged by a moderation direct 1. - A slight force either rotary or direct and become dislodged or both. 4. Condition of the Tissues

of rotary force but is disis applied to one side. of rotary force and was force. causes the denture to move

4. - Tissues are firm and appear healthy with no signs of abrasion or other injury caused by the dentures. 3. - The tissues are generally firm and appear healthy except for small isolated regions. 2. - Some movable tissue on the crest of ridge not previously present or irritated regions covering one-third of the denture bearing area. 1. - Large general regions of redness involving half or more of the denture bearing surface or a considerable amount of movable tissue not present before or both. areas are to be scribed on the drawings and the coding used: R - Redness (isolated) I - Inflammation (general) H - Hyperplastic Tissue U - Ulceration Fig. 1. A rating legend was maintained in each patients record. The format for &is form was developed by Dr. Julian Woelfel, The Ohio State University College of Dentistry. All abnormal following

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SUBJECTIVE Patient 1. Centric 2. Relation

EVALUATION Initial Recall

- Centric Occlusion

Upper Retention - The denture is grasped by the thumb and index finger in the posterior area and a downward force applied. - Direct force is applied in the center of upper incisors. - Patient is instructed to go through facial muscle gymnastics. 4 3 2 1 I

3. Upper Stability

I Direct force is applied on right and left sides in 1st molar region. Denture is grasped by the thumb and index finger in the posterior area and a rotational force applied.
4 3 2 1

4. Lower Retention

1 An explorer is placed in the imbrasure between the two central incisors. The tongue is placed in an anterior position and upward pressure is applied.

5. Lower Stability Direct force is applied on right and left sides in 1st molar region. Denture is grasped by the thumb and index finger in the posterior area and rotational force applied. 6. Condition of Upper Tissues (A mirror picture of palate is made) PIP records Direct force is applied simultaneously by the thumb and index fingers of one hand in the posterior areas and the thumb of the other hand in the incisor area. , 7. Condition of Lower Tissues (Picture of lower ridge) PIP records f&P
R L

0 4; 3, ajljl

Fig. 2. The dentist making the evaluation recorded his findings on this form by checking the appropriate square. If half-number evaluations were made, the check was placed between the two squares.

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I

J. Prod&. Dent. August, 1971

Table I. Mean evaluation

for each variable

New denture Mean 3.38 3.79 3.63 3.34 3.67 3.23 3.26 1 Standard deviation 0.4877 0.3971 0.4.123 0.5525 0.4007 0.5615 0.5543 i ; fi <O.OOl <O.OOl <o.oor <O.OOl <O.OOl <a.001 <O.OOl

Old denture Mean 2.04 1.98 1.88 1.55 1.63 2.56 2.64 Standard deviation 0.7856 0.6412 0.6175 0.6460 0.6585 0.7159 0.7548

Variable Centric relationcentric occlusion Maxillary retention Maxillary stability Mandibular retention Mandibular stability Maxillary tissues Mandibular tissues

to incorporate bilateral balanced occlusions in the Group I patients other than in centric relation. Each patient was subjectively evaluated on two occasions. The first evaluation was made of the patients present dentures before treatment was begun. The second evaluation was made of the new dentures on the day they were initially placed in the mouth. On both occasions, the subjective evaluations were performed by three of the five project dentists. The evaluating dentists were not aware of the patients group designation nor did they have access to the evaluation findings of the other examining dentists, However, they were completely familiar with the criteria to 1~1 used for the evaluation. Seven characteristics were evaluated on both occasions. They were ( 1 j harmony of centric relation and centric occlusion, (2) retention of the maxillary denture, (3) stability of the maxillary denture, (4) retention of the mandibular denture, (5) stability of the mandibular denture, (6) condition of the maxillary supporting tissues, and (7) condition of the mandibular supporting tissues. Each was evaluated on a seven-point scale with the criteria for evaluation contained in a printed form (Fig. 1) . Evaluations were recorded on a separate form (Fig. 2) . While the evaluation forms contained provision for only four number judgements (1, 2, 3, and 4)) half steps (1.5, 2.5, and 3.5) were also included to make up the seven-point evaluation system.

RESULTS
The mean evaluations and standard deviations given by the three evaluators for each variable for both the old and the new dentures are shown in Table I. The standard deviation of each variable for the new dentures was smaller than the standard deviation for the old dentures indicating that the range or spread of evaluation was less for the .new dentures. All variables were significant at the 0.001 level. The increase in the over-all mean evaluation for the new dentures was too large and consistent to be attributed to error. The confidence level was well beyond 99.9 per cent. The correlations among the three dentists and the average correlation for each variable for the old and new dentures are shown in Table II. The average correlation for each of the seven variables in the old dentures ranged from 0.52 to

Subjective evaluation
Table II. Correlation variable measured among dentists and average

in clinical
for each

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115

correlation

Occasion

Dentist

Centric relationcentric occlusion

Maxillary retention

Maxillary stability

Mandibular retention

Mandibular stability

Maxillary tissue

Mandibular tissue

Old denture

1 vs 2 1 vs 3 2 vs 3
Average Correlation

0.64 0.55 0.58

0.59

0.65 0.42 0.41 0.58 0.43 0.52 0.60 0.53

0.60 0.31 0.38 0.52 0.40 0.57 0.38 0.47

0.63 0.42 0.47 0.52 0.36 0.36 0.63 0.50

0.48 0.57 0.49 0.52 0.18 0.44 0.48 0.42

0.62 0.52 0.69 0.62 0.32 0.38 0.59 0.47

0.70 0.65 0.60 0.65 0.42 0.49 0.53 0.49

New denture

1 vs 2 1 vs 3 2 vs 3
Average Correlation

0.48 0.50 0.45

0.49

Table

Ill. Variation

in evaluation

among dentists

Instances of evaluation with deviation greater than one whole

Centric
relationcentric occlusion 1

ManMaxillary retention Maxillary stability dibular retention

number Old denture New denture

Mandibular stabilitv

Maxillary tissue 1

Mandibular

tissue 2 5

2 1

2 0

5 2

5 1

0.65. The average correlation for each variable with the new dentures ranged from 0.42 to 0.53. The reduced correlation in the new dentures was probably caused by the higher evaluations given these dentures which approached the upper limit of the evaluations scale reducing the scatter and lowering the correlation. The fact that the average correlation among the seven variables was of the same magnitude indicates that the dentists were not able to evaluate one variable with more accuracy than another. The number of times that one of the three evaluators varied from the others by more than one whole number is shown in Table III. The maximum number of times that at least one evaluator differed from the others by more than one whole rating number for any one variable was five. This indicates that, while there was not always total agreement among the three dentists for each variable, they did not vary far or often. Table IV presents the number of patients and percentage of patients for both the old and new dentures ( 1) for whom each evaluator assigned a different rating, (2) where two of the evaluators agreed on the rating assigned for each of the

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variables, and (3) where the evaluators all agreed on the rating assigned for each of the variables. In 58.8 per cent of the evaluations of the coincidence of centric occlusion with centric relation, there was agreement among all evaluators for the old dentures. However, agreement dropped to 38.5 per cent with new dentures. Thus, a complete lack of harmony in the occlusion is probably easier to subjectively evaluate than a more harmonious relationship as was found with the new dentures. Agreement of evaluation of retention for the old maxillary dentures was only 33.3 per cent. However, agreement rose to a high of 69.2 per cent for the new maxillary dentures. Apparently, a lack of maxillary retention is more difficult to subjectively determine than the presence of maxillary retention. Agreement of evaluation for stability of old maxillary dentures was 41.2 per cent and 53.8 per cent for the new dentures. Much of denture stability is a function of the form, shape, and size of the residual ridge and the form of the denture base. The influence of the supporting tissue makes evaluation of stability difficult and may account for the relative closeness of the agreement of the evaluators even though the mean evaluation (Table I) was much higher for the new dentures. The agreement in evaluation of retention for old mandibular dentures was 60.8 per cent and that for new dentures was 42.3 per cent. The mean evaluation for the old dentures was 1.55 and for the new it was 3.34 per cent (Table I). Thus, there was an obvious increase in the over-all retention of the new mandibular dentures, and yet the evaluators had a more difficult time agreeing on the rating of the new dentures. Evaluators could determine minimum retention more unanimously than they could determine the degree of retention that did exist. Agreement in evaluation of stability for mandibular dentures was 65.7 per cent for the old dentures and 51.9 per cent for the new dentures. A definite increase of mean stability was found for the new dentures (Table I), but the percentage of agreement of the evaluators changed little in the two evaluations. The higher percentage of agreement on the evaluation of the old dentures indicates that a lack of stability was easier to evaluate than was the degree of stability of the new dentures. The percentage of agreement for evaluation of the maxillary and mandibular supporting tissues was similar for both dental arches on both evaluations with slightly less agreement on the lower arch. This may be attributed to the increase of movable tissues on the lower residual ridge making this evaluation more difficult. No effort was made to evaluate the amount of resorption of the residual ridges. However, extreme resorption may have caused some confusion in the minds of the dentists making the evaluations.

SUMMARY

AND CONCLUSIONS

Seven clinical variables were evaluated on old and new dentures for a group of 52 edentulous patients by three dentists. The data collected were analyzed to determine the value of subjective evaluations. The following conclusions were drawn ( 1) Three dentists using the same evaluation criteria cannot from the data: However, the degree of deviation is independently arrive at an exact evaluation. small. (2) Of the seven variables evaluated, the dentists were unable to evaluate

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one more accurately than another. (3) An existing complete denture can be evaluated as accurately as a new one. (4) A subjective evaluation by one dentist is not reliable. However, reliability does exist when several dentists using the same criteria evaluate the same characteristic and their evaluations are averaged.
DR. JACK H. RAYSON: LOUISIANA STATE UNIVERSITY SCHOOL OF DENTISTRY 1190 FLORIDA AVE. NEW ORLEANS, LA. 70119 DRS. HENDERSON, WESLEY, LUTES, FRAZIER, ELLINGER, AND HALEY: UNIVERSITY OF KENTUCKY MEDICAL CENTER COLLEGE OF DENTISTRY LEXINGTON, KY. 40506 DR. ARTHUR 0. RAHN: MEDICAL COLLEGE OP GEORGIA COLLEGE OF DENTISTRY AUGUSTA, GA. 30902