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Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2015 42; 40--48

Oral health-related quality of life of removable partial


denture wearers and related factors
S. SHAGHAGHIAN*, M. TAGHVA, J. ABDUO & R. BAGHERI

*Oral Public Health Depart-

ment, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, , Prosthodontic Department, School of Dentistry, Shiraz University
of Medical Sciences, Shiraz, Iran, Restorative Department, Melbourne Dental School, Melbourne University, Melbourne, Vic., Australia and

Dental Material Department and Biomaterial Research Centre, School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran

SUMMARY This study aims to investigate the oral


health-related quality of life (OHRQoL) in a group
of removable partial denture (RPD) wearers in
Shiraz (Iran), using the Persian version of the Oral
Health Impact Profile (OHIP-14). Two hundred
removable partial denture wearers had completed
a questionnaire regarding patients demographic
characteristics and denture-related factors. In
addition, the OHIP-14 questionnaire was filled out
by interviewing the patients. Two measures of
interpreting the OHIP-14 scales were utilised:
OHIP-14 sum and OHIP-14 prevalence. The
relationship
of
the
patients
demographic
characteristics and denture-related factors, with
their OHRQoL was investigated. The mean OHIP14 sum and OHIP-14 prevalence of RPD wearers
were 1380 (1008) and 445%, respectively. The
most problematic aspects of OHIP-14 were physical
disability and physical pain. Twenty-seven
percentage and 24% of participants had reported

Introduction
Tooth loss is the outcome of various factors such as
caries, periodontal disease, pulpal pathology, trauma
and oral cancer and may result in chewing difficulties
that affect general health and quality of life (1). Several treatment options, such as implant, fixed or
removable prostheses, can be proposed to replace the
missing teeth. Although the interest in dental
implants is continuously growing, many edentulous
patients are still treated by conventional removable
prostheses. The removable partial denture (RPD) is
2014 John Wiley & Sons Ltd

meal
interruption
and
eating
discomfort,
respectively. OHIP-14 prevalence and OHIP-14 sum
were found to be significantly associated with
factors representing RPD wearers oral health such
as self-reported oral health and frequency of
denture
cleaning.
Furthermore,
OHIP-14
prevalence and OHIP-14 sum were significantly
associated with factors related to frequency of
denture use such as hours of wearing the denture
during the day and wearing the denture while
eating and sleeping. Therefore, it can be concluded
that the OHRQoL of the patients of the study was
generally not optimal and found to be strongly
associated with oral health.
KEYWORDS: oral health, quality of life, removable,
partial, denture
Accepted for publication 30 July 2014

selected by many partially edentulous patients


because it is conservative in nature, quickly provided
and economical (2).
Like other countries, Iran experienced improvement
in oral health parameters including reduction of edentulous patients rate and, consequently, their need for
denture treatment. However, as the population is
growing in Iran, the number of edentulous patients
will increase. It has been estimated that by 2050, the
number of edentulous patients will increase by a factor of four in comparison with the edentulous
patients number reported in year 1975 (3). Therefore,
doi: 10.1111/joor.12221

ORAL HEALTH OF DENTURE WEARERS


it is important to consider edentulous patients need
and the factors that influence their quality of life.
It has been shown that many biological, mechanical, aesthetic and psychological factors are related to
acceptance of prosthesis and success of treatment (2).
Of these factors, mastication and phonation were proven to be important factors while age, health and
hygiene were not found to be associated with satisfaction (2). Mechanical factors such as denture fit, retention and number of missing teeth were also associated
with satisfaction in RPD wearers (4).
In many instances, patients satisfaction is subjective and varies from individual to individual. Furthermore, it was shown that clinicians evaluation of
removable prostheses differs from patients appraisal.
Variables such as survival rate, longevity of the prostheses and frequency of complications have been considered as the more important for clinicians; while the
social and psychological impacts of treatment and cost
effectiveness are more important factors from the
patients perspective (5). Oral health impact profile
(OHIP) assesses patients perceptions of oral health
which has been used for measuring OHRQoL of
removable denture users and proved to be a suitable
means of measurement (6).
The OHIP questionnaire is based on a model of oral
health adapted for dentistry by Locker (7). The original OHIP questionnaire was developed by Slade and
Spencer (8) and had 49 items. OHIP-14 was developed as a modified and abbreviated version of the original OHIP and was selected as an instrument of
choice to assess OHRQoL in the elderly (9). To date,
effect of wearing RPD in the OHRQoL among Iranian
patients is lacking. Therefore, in this study, Persian
version of OHIP-14 was used to investigate OHRQoL
of a sample of RPD wearers in Iran.

Materials and methods


This cross-sectional study was conducted in 2012 in
Shiraz Dental School, the most important referral centre for patients in the southern part of Iran. The list of
all prosthodontic practitioners was obtained from Shiraz University of Medical Sciences (over all 17 specialists). Ethical approval was also obtained from the
Ethics Committee of the Shiraz Dental School (Application # 4476). Convenience sampling was carried
out by selecting 253 patients from who referred to
Shiraz Dental School and all the prosthodontics
2014 John Wiley & Sons Ltd

practices. A package containing an information brochure explaining the aims and a consent form was
given to the selected participants in the study. The
following were the inclusion criteria: Patients wearing
either double or single RPD for at least 8 weeks old
with or without complete dentures. Questionnaires
were filled by interviewing with each patient.
This questionnaire consisted of two parts. The first
part was comprised of patients demographic characteristics (age, sex and self-reported oral health) and
denture-related factors (eight questions). The next
part consisted of all 14 questions of Persian version of
(OHIP-14) that has been validated by Navabi et al.
after translation into Persian and adaptation to the
Iranian culture. The authors speculated that it is a
precise, valid and reliable instrument for assessing oral
health-related quality of life among Iranian population (10).
Each question of the OHIP-14 questionnaire was
scored between zero and four (0 = never, 1 = hardly
ever, 2 = occasionally, 3 = fairly often, 4 = very
often). Two measures of interpreting the OHIP-14
scales, OHIP-14 sum and OHIP-14 prevalence, were
utilised to describe RPD wearers OHRQoL. The OHIP14 sum was calculated as sum of the 14 questions
scores. The scores had a possible range of 056; the
higher scores representing the worse OHRQoL. OHIP14 prevalence was determined as the percentage of
people reporting one or more OHIP-14 items, with a
fairly often/very often response.
The collected data were analysed by adapting the
SPSS package (version 18*). The independent sample
t-test, one-way ANOVA (with Tukey post hoc test) and
chi-square test were used to assess the relationship of
patients demographic characteristics and denturerelated factors with their OHQoL. To control the effect
of possible confounding factors, the variables were
entered in a multiple logistic regression model with
OHIP-14 prevalence as the dependent variable. An
alpha level of 005 was regarded as statistical significance.

Results
Of the 253 RPD wearers, who were invited for the
interview, 200 patients participated in the study

*SPSS Inc., Chicago, IL, USA.

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S . S H A G H A G H I A N et al.
Table 1. Characteristics of studied partial removable denture
wearers (N = 200)
Characteristics

Number (%)

Sex
Male
Female
Age
<50 years old
50 years old
Number of arch
One partial denture
Two partial denture
One partial and one
complete denture
Duration of denture
experience
1 year
>1 year
Denture material
Only resin
Only Chromecobalt
One resin and one
Chromecobalt
Hours of wearing per day

78 (390)
122 (610)
90 (450)
110 (550)
110 (550)
84 (420)
6 (30)

102 (510)
98 (490)
76 (380)
110 (550)
14 (70)

39 (195)
03 h day

use
39 (195)

414 h day

use
85 (425)

1523 h day

use
37 (185)

24 h day 1 use
Wear when eating
Always
Sometime
Never
Wear when sleeping
Always
Sometime
Never
Cleaning frequency

98 (490)
68 (340)
34 (170)
27 (135)
52 (260)
121 (605)
35 (175)

01 time week

27 time week

97 (485)
68 (340)
>7 time week 1
Self-reported oral health
Good
Fair
Poor
Stability during chewing
and speaking
Always stable

87 (435)
58 (290)
55 (275)

49 (245)

Table 1. (continued)
Characteristics

Number (%)

Sometime stable
Never stable
Satisfaction of the denture
Yes
No
Not responding

135 (675)
16 (80)
122 (610)
70 (350)
8 (40)

(acceptance rate = 79%). One hundred and ten participants (55%) were 50 years old or older and 122
(61%) were women. Almost half of them had used
their denture more than 1 year. Self-reported oral
health of 435% of them was good and 61% were satisfied with their dentures (Table 1).
OHRQoL of RPD wearers
A total of 89 participants answered at least one item
as very often/fairly often, (OHIP-14 prevalence = 445%). The aspects of OHIP-14 in which the
participants had problems very often/fairly often were
widely different. The most problematic aspects were
physical disability and physical pain so that 27% and
24% of participants had interrupted meals and were
uncomfortable to eat, respectively. On the contrary,
the participants had little problem in handicap and
social disability aspects so that only 25% of them
were unable to function and a similar percentage had
difficulty doing jobs (Table 2). OHIP-14 sum for the
study participants was from 0 to 40 and the mean
was 1380  1008 (Fig. 1).
Relationship between patients characteristics and their
OHRQoL
There was not a statistically significant association of
OHIP-14 sum and OHIP-14 prevalence with the following variables: sex, number of arches and duration
of partial removable denture use (Table 3). Two variables, age and denture material, were significantly
related to OHIP-14 sum but not to OHIP-14 prevalence. However, both OHIP-14 prevalence and OHIP14 sum were significantly associated with denture stability. Patients whose dentures were always stable
during chewing and speaking had the lowest scores of
OHIP-14 prevalence (P < 0001) and OHIP-14 sum
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ORAL HEALTH OF DENTURE WEARERS


(P = 0013). Similarly, these two measures of OHRQoL were significantly associated with variables indicating RPD wearers oral health, that is frequency of
denture cleaning and self-reported oral health.
There was a statistically significant relationship
between self-reported oral health and OHIP-14 prevalence and OHIP-14 sum so that the participants with
good oral health had the lowest scores in both measures (improved OHRQoL) (P < 0001). Likewise, a
significant association was found between OHIP-14
prevalence and OHIP-14 sum and frequency of denture cleaning (P < 0001). The more the RPD wearer
cleaned the denture, the lower OHIP-14 scores (better
OHRQoL) were detected.
All three factors indicating frequency of denture
use, such as hours of wearing denture in a day, wearing dentures when eating and when sleeping, were
significantly associated with both measures of OHRQoL. With respect to hours of wearing denture, the
OHRQoL of the patients not using their dentures or
using it/them a few hours per day was the worst
(P < 0001). This was also true for patients never
wearing their dentures when eating (P < 0001) and
when sleeping (P < 0001).
Logistic regression analysis showed a significant
association of OHIP-14 prevalence with the variable
indicating RPD wearers oral health, frequency of
denture cleaning, and one of the variables representing frequency of denture use, that is wearing denture

Table 2. Distribution of Oral Health Impact Profile-14(OHIP14) for each single item (N = 200)

OHIP-14 item
Functional limitation
Trouble
pronouncing
words
Taste worse
Physical pain
Painful aching
Uncomfortable
to eat
Psychological
discomfort
Self-conscious
Tense
Physical disability
Diet unsatisfactory
Interrupt meals
Psychological
disability
Difficult to relax
Been embarrassed
Social disability
Irritable with others
Difficulty doing jobs
Handicap
Life unsatisfying
Unable to function

Very often
& fairy
often
N (%)

Occasionally
N (%)

Hardly
ever & never
N (%)

15 (75)

25 (125)

160 (800)

15 (75)

38 (190)

147 (735)

38 (190)
48 (240)

50 (250)
56 (280)

112 (560)
96 (480)

15 (75)
40 (200)

32 (160)
38 (190)

153 (765)
122 (610)

47 (235)
54 (270)

34 (170)
67 (335)

119 (595)
79 (395)

42 (210)
7 (35)

44 (220)
24 (120)

114 (570)
169 (845)

7 (35)
5 (25)

19 (95)
10 (50)

174 (870)
185 (925)

6 (30)
5 (25)

11 (55)
9 (45)

183 (915)
186 (930)

100

Cumulative percent

80
75 percentile
60

40

25 percentile

20

Fig. 1. Cumulative distribution of


Oral Health Impact Profile-14 scores
in removable denture wearers
(N = 200).
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8 10 12 14 16 18 20 22 24 26 28 30 32 35 37 40
Oral health impact profile-14 score

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S . S H A G H A G H I A N et al.
Table 3. Bivariate analysis showing factors affecting oral health-related quality of life of partial removable denture wearers (N = 200)
OHIP sum
Mean  SD

Characteristics
Sex
Male
Female
Age
<50 years old
50 years old
Number of arches
One
Two
Duration of partial removable denture use
1 year
>1 year
Hours of wear
1

03 h day
414 h day

1523 h day

OHIP prevalence
P-value

N (%)

P-value

127  101
145  100

0213*

32 (41)
57 (467)

0429***

154  103
125  97

0047*

45 (50)
44 (40)

0157***

142  106
138  94

0793*

52 (473)
37 (411)

0383***

141  99
134  103

0635*

48 (471)
41 (418)

0458***

250  93a

<0001**

35 (897)

<0001***

use
1

166  75b

19 (487)

95  71c

23 (271)

88  88c

12 (324)

use
1

use

24 h day use
Denture material
Only resin
Only Chromecobalt
One resin and one Chromecobalt
Wear denture when eating
Always
Sometime
Never
Wear denture when sleeping
Always
Sometime
Never
Cleaning frequency
01 time week

27 time week

>7 time week 1


Stability during chewing and speaking
Always stable
Sometime stable
Never stable
Self-reported oral health
Good
Fair
Poor

115  94a
155  105b
131  87ab

0030**

28 (368)
56 (509)
5 (357)

0131***

82  71a
158  83b
261  82c

<0001**

21 (214)
35 (515)
33 (971)

<0001***

78  74a
102  84a
167  102b

0001**

8 (296)
113 (250)
68 (562)

<0001***

261  76a

<0001**

32 (914)

<0001***

121  88b

37 (381)

99  79b

20 (294)

71  75a
156  91b
186  150b

<0001**

13 (265)
67 (496)
9 (563)

0013***

81  63a
127  82b
240  89c

<0001**

12 (138)
28 (483)
49 (891)

<0001***

N, number; s.d., standard deviation.


Different letters show statistically significant differences.
*Independent sample t-test.
**One-way ANOVA.
***Chi-square test.
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ORAL HEALTH OF DENTURE WEARERS


when eating (Table 4). Those participants who
cleaned their denture less than once per day were
three times more likely to frequently experience each
problems mentioned in OHIP-14 questionnaire than
those cleaning it/them once or more per day (95%
CI: 133714). Despite the significant association
between the OHIP-14 prevalence and all indicators of
frequency of denture use in univariate analysis, no
statistically significant association was found between
the OHIP-14 prevalence and two items indicating frequency of denture use, that is hours of wearing denture during the day and wearing dentures when
sleeping in multivariate analysis. However, there was
a significant association between this measure of
OHRQoL (OHIP-14 prevalence), and the other item
indicating frequency of denture use, wearing dentures

Table 4. Multiple logistic regression model with Oral Health


Impact Profile-14 prevalence as the dependent variable
(N = 200)
Independent
variables

SE

OR

95% CI for OR

Sex (/male)
Female
065 038 191
091403
Age (/50 years old)
<50 years old
008 037 109
053223
Number of arches (/two)
One
028 036 133
065271
Duration of partial removable denture use (/>1 year)
1 year
023 038 079
038168
Denture material (/resin)
Chromecobalt
005 039 095
044205
Hours of wear
(/24 h day 1)
048 068 062
016237
Lower than
24 h day 1
Wear when eating (/always)
Never or
185 041 637 2831433
sometime
Wear when sleeping(/always)
Never or
001 078 099
021463
sometime
Cleaning frequency (/once or more per day)
Lower than
127 043 309
133714
once per day
Stability during chewing and speaking(/always)
Never or
037 045 145
060350
sometime

0086
0822
0434
0547
0897

0486

<0001

SE, standard error; OR, odds ratio; CI, confidence interval.


2014 John Wiley & Sons Ltd

0999

0008

0404

when eating. Odds ratio for patients never wearing or


sometimes wearing their RPD when eating in comparison with those always wearing it was 637 (95% CI:
2831433).

Discussion
For the majority of people, oral health has an impact
on the quality of life as it could influence comfort,
function and aesthetics. This study discloses some of
the variables that affect the quality of life of patients
treated with RPD. The duration of wearing RPD,
denture cleaning frequency, denture stability and
self-reported oral health were found to positively
contribute to OHRQoL. On the other hand, sex, age,
number of dentures, period of RPD wear and denture
material were found to minimally influence the
OHRQoL.
Overall, although the OHIP-14 values in this study
indicated favourable OHRQoL for patients with RPDs,
the prevalence of RPD-related problems was relatively
considerable. This observation was in accordance with
several studies that utilised OHIP to measure OHRQoL
for patients with RPDs (11, 12) Patients dissatisfaction
with RPD could be related to the nature of the RPD
treatment. RPD treatment consumes more clinical
time, and the patients will require high maintenance
rate (13). This was found to contribute to poor satisfaction with RPD and loss of patient motivation (14).
This finding is in accordance with a Korean study that
utilised OHIP and found the RPD users had higher
scores than complete denture users. Their participants
reported that the RPD was associated with more discomfort, social limitations and cleaning difficulties (6).
Likewise, a German study found that patients treated
with RPD tend to suffer from prosthesis related complaints for greater duration than patients treated with
fixed dental prostheses (12). The most common complaints were sore spots, painful gums, denture-related
discomfort and sore jaw (12). The results of our study
was comparable to that of Abuzar et al. (15); the
OHIP-14 prevalence in our study (445%) was slightly
higher than the OHIP-14 prevalence obtained from
Australian RPD wearers (431%) while the OHIP-14
sum in this study (138) was slightly lower than that
of Australian (148). Therefore, it is speculated that
the participants in Iran have similar reaction to RPD
in comparison with participants of some other studies
(15).

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S . S H A G H A G H I A N et al.
This study indicates that 50-year old participants or
older have less scores of OHIP sum than younger participants. In the literature, there is conflicting evidence about the impact of patient age on the
acceptance of RPD. Similar to the current studies, Wakabayashi et al. (16) found that younger patients
(<65 years) tend to be less aesthetically satisfied with
their denture than older patients. Likewise, Frank
et al. (17) found that younger patients (less 60) tend
be more dissatisfied about their denture treatment.
Kimura et al. found younger patients treated with
RPD have less OHRQoL. Such outcome could be
attributed to higher social demand and self-concerns
with aesthetics and oral function in comparison with
older patients (18). On the other hand, older patients
are more experienced to function with missing teeth
(19). On the contrary, Koyama et al. (20) found that
the older the patients (more than 65 years), the less
likely to wear their RPDs. They anticipated that older
individuals might have less aesthetic and social
demands and more impaired neuromuscular control,
which could make them more indifferent to the treatment.
There are signs that patients wearing acrylic partial
denture ranked their OHRQoL higher than those
wearing metal partial denture. This observation is
opposite to what many specialists would regularly recommend. However, in removable prosthodontics, discrepancies between clinician objective appraisal and
patient subjective preference is not uncommon (20).
Still, these results should be interpreted with caution.
In many instances, acrylic denture is indicated for
immediate aesthetic restorations, which can solve a
major patient concerns. Furthermore, acrylic dentures
are generally cheaper, require less treatment time and
are heavily used to restore missing anterior teeth.
These factors could explain why the reported OHRQoL by patients wearing acrylic partial denture
appears higher.
In addition, this study emphasises that drawbacks
of RPD are the physical problems such as pain and
lack of stability during chewing and speaking. This
could eventually influence patients comfort, eating
and meal interruption. The importance of RPD stability has been confirmed by a Japanese study, which
found that patients with more stable RPD had lower
OHIP scores (21). On that basis, improving RPD quality is very desirable (21) Thus it could be speculated
that restoring stability-related function by RPD, such

as chewing, is unreliable and might not be to the


level of patients expectations (2). The physical problems and lack of stability of RPD could be due to multiple reasons such as differential support, material
bulkiness and occlusion instability. In a retrospective
study, Koyama et al. (20) reported that completely
tooth supported RPDs were more preferred by
patients than tooth and tissue-supported RPDs, which
could be attributed to the superior stability and support. In the same study, it was shown that the better
the design and distribution of supporting rests, the
greater the satisfaction with the RPD, which could
also be associated with less pain during function. To
overcome the classical RPD problems, several authors
recommended RPD treatment alternatives such as
fixed prosthesis or shortened dental arch (SDA). There
is consistent observation that patients receiving
removable prosthesis had poorer OHRQoL than those
receiving fixed treatment (11, 22). On the other hand,
good level of evidence supports that for patients with
SDA, the RPD was found not to improve oral function
or prevent craniomandibular disorder, occlusion instability and tooth wear (23). Moreover, the OHRQoL
did not differ significantly between RPD patients and
SDA patients (24).
Similar to the observations by other authors (25),
the results of the present study indicate that patients
who ranked their self-reported oral health as good
had better OHIP values than those who reported it as
fair or poor. Similarly, participants regularly wearing
their RPDs or frequently cleaning it had better OHRQoL. This confirms the finding of other reports that
found patients who continuously wear their RPDs
were more satisfied with their denture treatment and
had better OHRQoL (19, 25). This reflects that acceptance of RPD is enhanced by the positive patient attitude towards his/her own oral health (2).
Philosophical patients might be more motivated about
the RPD treatment and will, eventually, be more satisfied and appreciative of the outcome.
This study indicates that RPD-related problems are
relatively frequent. It appears that the duration of
wearing the RPD, denture cleaning frequency, denture stability and self-reported oral health are positively associated with better OHRQoL. These factors
should be considered by the treating clinician and
explained to the patient when the RPD treatment is
planned and executed. Comparing the data of this
cross-sectional study with dental individuals might be
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ORAL HEALTH OF DENTURE WEARERS


beneficial or indicated in the future. Although the
number of teeth is an important physical characteristic for dental patient populations, it was not considered in this study which in turn is one of our study
limitations.

7.
8.
9.

Acknowledgments
The authors thank the Vice Chancellor of Shiraz University of Medical Sciences for supporting this
research (Grant # 4476).

Ethical considerations
The scientific and ethical aspects of the protocol were
reviewed and approved by the review board of the
Shiraz Dental School, the University of Medical Sciences, Shiraz, Iran. Informed consent was obtained
from all participants.

Funding

10.

11.

12.

13.

14.

15.

This research was supported by Vice Chancellor of


Shiraz University of Medical Sciences.
16.

Conflicts of interest
No conflict of interests declared.
17.

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Correspondence: Rafat Bagheri, Dental Material Department and
Biomaterial Research Centre, Shiraz University of Medical Sciences,
Shiraz Dental School, Ghomabad, Ghasrodasht St, Shiraz, Iran.
E-mail: bagherir@unimelb.edu.au

2014 John Wiley & Sons Ltd