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demand For proStethic

on impl ant dentiStry


dentiStry treatment
Swedish Dental Journal, Supplement 218, 2011

with Special FocuS


FactorS Shaping
Birger narBy

S w e d i S h d e n t a l j o u r n a l , S u p p l e m e n t 2 1 8 , 2 0 11 . d o c t o r a l d i S S e r t a t i o n i n o d o n t o l o g y
B i r g e r n a r By Fac t o r S S h a p i n g d e m a n d F o r p r o S t e t h i c d e n t i S t ry t r e at m e n t w i t h S p e c i a l F o c u S o n i m p l a n t d e n t i S t ry m a l m u n i V e r S i t y 2 011

malm uniVerSity
205 06 malm, Sweden
www.mah.Se
isbn/issn 978-91-7104-415-0 / 0348-6672
FACTORS SHAPING DEMAND FOR PROSTETHIC
DENTISTRY TREATMENT WITH SPECIAL FOCUS
ON IMPL ANT DENTISTRY
Swedish Dental Journal, Supplement 218, 2011

Birger Narby 2011


ISBN 978-91-7104-415-0
ISSN 0348-6672
Holmbergs, Malm 2011
BIRGER NARBY
FACTORS SHAPING
DEMAND FOR PROSTETHIC
DENTISTRY TREATMENT
WITH SPECIAL FOCUS ON
IMPL ANT DENTISTRY

Malm University, 2011


Department of Oral Public Health
and
Department of Prosthetic Dentistry
Faculty of Odontology
This publication is also available at:
www.mah.se/muep
To my wife and to my children
CONTENTS

PREFACE ....................................................................... 9
AbSTRACT .................................................................. 10
POPUlRvETEnSkAPlig SAMMAnFATTning .................. 12
inTRODUCTiOn .......................................................... 15
AiMS ......................................................................... 17
MATERiAlS AnD METHODS ........................................... 19
RESUlTS ..................................................................... 26
Study i ................................................................................ 26
Study ii ................................................................................ 29
Study iii ............................................................................... 32
Study iv .............................................................................. 33
Study v ............................................................................... 35
DiSCUSSiOn ............................................................... 39
Methodological discussion ..................................................... 39
Factual discussion ................................................................. 42
COnClUSiOn ............................................................ 53
ACknOwlEDgEMEnT ................................................. 56
REFEREnCES ............................................................... 58
PAPERS i v ............................................................... 67
APPEnDiCES ..............................................................129
PREFACE

This thesis is based on the following papers, which will be referred


to by their roman numerals:

I. Narby B, Kronstrm M, Sderfeldt B, Palmqvist S. Pros-


thodontics and the Patient: What is Oral Rehabilitation
Need? Conceptual Analysis of Need and Demand for
Prosthodontic Treatment.Part 1: A Conceptual Analysis.
Int J Prosthodont. 2005;18:75-79.
II. Narby B, Kronstrm M, Sderfeldt B, Palmqvist S.
Prosthodontic and the Patient. Part 2:Need Becoming
Demand, Demand Becoming Utilization. Int J Prostho-
dont.2007;20:183-189.
III. Narby B, Kronstrm M, Sderfeldt B, Palmqvist S. Chang-
es in Attitudes Toward Desire for Implant Treatment: A
Longitudinal Study of a Middle-Aged and Older Swedish
Population. Int J Prosthodont. 2008;21:481-485.
IV. Narby B, Collin Bagewitz I, Sderfeldt B. Factors Ex-
plaining Desire for Dental Implant Therapy: Analysis of
the Results from a Longitudinal Study. Int J Prostodont.
2011;24:437-444.
V. Narby B, Hallberg U, Collin Bagewitz I, Sderfeldt B.
A Grounded Theory on Important Factors Involved in
Treated Patients Decision-making Process for Implant
Therapy. Int J Prosthodont. Accecpted 2011-08-03

The articles are reprinted with kind permission from Quintessence


Publishing Co Inc.

9
ABSTRACT

Aim: The main aim of this thesis was to investigate how attitudes
influence the latent and manifest need, desire, demand, and utilization
for dental implant treatment, considering the gatekeeping process
between need and demand, and between demand and utilization of
dental treatment.

Material and Methods: A conceptual analysis of the need and


demand concept from the literature was a first step in the study. A
second step was to examine changes in attitudes toward desire for
implant treatment over time, also in relation to dental status, in a
population of middle aged and older individuals in Sweden based on
two questionnaire studies, one in 1989 and the other in 1999 among
the same 3000 participants. The individuals who responded both
in 1989 and 1999 constituted a panel of 56% of the 1989 survey
sample. Logistic regression models were done with desire of implant
treatment as dependent variable. In paper V, a qualitative study
using grounded theory was done on the treated patients subjective
perspective on receiving a fixed implant-supported denture.

Results: An emancipatory perspective with the patient-dentist


dialogue was regarded as central for an optimal treatment result in
the prosthetic treatment decision-making process. A main finding
was that need is established only in a communicative dialogue
with mutual respect between the profession and the patient. The
study implied that the gatekeeping concept relates to a complex
process rendering great differences between demand and actual
utilization. The main result from the questionnaires was the huge

10
increase in interest for implant-treatment from 1989 to 1999. In
1999 almost all (94%) of the study population expressed desire
for implant treatment; as many as 92 % percent of those who did
not express a desire for implants in 1989 had changed their mind
10 years later. The regression analysis showed that older people,
non-city residents, and those with one or several missing and un-
replaced teeth, changed desire for implant treatment between the
study years. Effects of age, residence, and better dental status
disappeared during the ten year study period. Those edentulous
and those with removable dentures expressed less desire than those
with all teeth remaining, or only one or a few teeth missing, in
1989. High income significantly increased the probability to desire
implant treatment for the study panel at both study occasions. The
qualitative study, using the method for grounded theory, gave as
core category and main finding the importance of the patients
trust and confidence in the dentist and his/her staff, in the process
of transforming desire for dental implant treatment into manifest
demand, and also making it more likely for the patients to become
satisfied with the treatment result regardless of complications.

Conclusion: There is no objective need in prosthodontic treatment.


Manifest need and demand change over time, and are influenced
by the patients attitude and situation, and by the dentists practice
profile. True need can only be identified in a dialogue between the
professional and the patient.
Income and dental status, but not age, place of residence, nor
concern for dental appearance, influence desire for implant treatment
at the end of the studied 10-year period. Individuals with removable
dentures, or those being edentulous in one or both jaws have a lower
probability to desire implant treatment than those with all teeth
remaining, or with missing teeth replaced by fixed partial dentures.
The qualitative study underlined the importance of the relationship
between the professional and the patient. The patients trust and
confidence in the dentist and his/her staff were decisive in the process
of making a demand for implant treatment manifest and turning
it into actual utilization. The informants from this study described
their confidence and trust as dependent on a communicative dialogue
with mutual respect between the patient and the professional.

11
POPULRvETENSkAPLIG
SAMMANFATTNING

Syfte: Det primra syftet fr denna avhandling var att underska hur
attityder pverkar latent och manifest behov, nskeml/efterfrga
samt ven hur attityder pverkar vrdutnyttjande av protetisk
rekonstruktion med hjlp av kkbensfrankrade implantat, med
speciellt intresse fr gatekeeping/hinders-processerna mellan behov
och efterfrga och mellan efterfrga och vrdutnyttjande.

Material och Metod: Som frsta steg i avhandlingen gjordes


begreppsanalys av begreppen behov och efterfrga (need and
demand), som de beskrivs i litteraturen. Som andra steg undersktes
attitydfrndringar gllande processen att eventuellt efterfrga
implantatbehandling, som skedde under ett decennium, hos en grupp
av medellders och ldre i Sverige, i relation till bl.a. tandstatus.
Denna studie baserades p tv enkter till samma 3.000 deltagare,
den frsta enkten 1989 och den andra 1999. De som besvarade
bda enkterna, 56% av de ursprungliga 3.000 deltagarna, utgjorde
panelen i denna studie. De statistiska analyserna utfrdes med logistisk
regression dr nskeml/efterfrga var den beroende variabeln. I
artikel V, en kvalitativ studie, anvndes metoden grounded theory
fr att underska behandlade patienters subjektiva uppfattning om
att bestmma sig fr och drefter genomg behandling fr att f en
fast kkbensfrankrad bro.

Resultat: Fr att uppn ett optimalt resultat av beslutsprocessen


gllande eventuell implantatbehandling var en dialog mellan

12
behandlare och patient, genomfrd med ett emancipatoriskt
perspektiv, helt central. Ett huvudsakligt fynd var att ett behov
uppstr i en kommunikativ dialog, genomfrd med msesidig
respekt mellan profession och patient. Studien pekar p att
gatekeeping problematiken r en komplex process som kan resultera
i stora skillnader mellan efterfrga och verkligt vrdutnyttjande.
Huvudfyndet frn enkterna var den mycket stora kningen av
intresse fr implantatbehandling frn 1989 till 1999. Nstan alla
(94%) i studiepopulationen uttryckte 1999 nskeml om implantat
behandling. S mnga som 92% av dem som inte uttryckte
nskeml om implantatbehandling 1989 hade ndrat sikt 10 r
senare. Den statistiska regressionsanalysen visade att ldre, personer
bosatta utanfr ttort och de som saknade en eller flera tnder hade
ndrat sikt angende nskeml om implantatbehandling mellan
tidpunkterna fr de bda enkterna. Effekten av lder, bostadsort
samt bttre tandstatus frsvann under tiorsperioden. Tandlsa
patienter och ven de med avtagbara proteser uttryckte 1989 mindre
nskeml/efterfrga n de som hade alla tnder kvar eller som
saknade en eller ett ftal tnder. Hgre inkomst kade signifikant
sannolikheten i studiepanelen, vid bda enkttillfllena, att efterfrga
implantatbehandling. Resultatet frn den kvalitativa studien, dr
grounded theory anvndes som metod, gav som krnkategori
och huvudfynd den stora betydelsen av att ha frtroende fr och
att lita p tandlkaren och hans eller hennes medarbetare, fr att
ett nskeml om implantatbehandling skall transformeras till en
manifest efterfrga. En frtroendefull relation hade ocks samma
stora betydelse fr att patienten skulle bli njd med resultatet av
behandlingen oavsett eventuella komplikationer.

Sammanfattning: Det finns inget objektivt behov av protetisk


behandling. Manifest behov och vrdefterfrga frndras med tiden
och pverkas av patientens attityd och situation och av behandlande
tandlkares vana av och intresse fr olika terapier. Verkligt behov
kan bara identifieras i en dialog mellan behandlare och patient.
Inkomst och tandstatus pverkade ett eventuellt nskeml om
implantatbehandling vid slutet av den underskta 10-rsperioden,
vilket inte lder, bostadsort och intresse fr det dentala utseendet
gjorde. Individer med avtagbara proteser eller de som var tandlsa

13
i en eller bda kkarna hade en lgre sannolikhet att efterfrga
implantatbehandling n de med alla tnder kvar eller de individer
dr saknade tnder var ersatta av fast protetik.
Den kvalitativa studien understrk betydelsen av ett frtroendefullt
frhllande mellan tandvrdspersonalen och patienten. Patientens
frtroende och tillit till tandlkaren och hans eller hennes
medarbetare var avgrande i den beslutsprocess dr ett behov av
implantatbehandling blir manifest fr att drefter frvandlas till
verkligt vrdutnyttjande. Informanterna frn den kvalitativa studien
beskrev att deras frtroende och tillit grundades p en dialog med
msesidig respekt mellan patient och behandlare.

14
INTRODUCTION

Many middle-aged persons share memories of older relatives who


every evening put their teeth into a glass of water. This changed
their appearance and seemed to diminish their self-esteem. With a
personal note, my own grandparents wore dentures from their early
middle-age and I remember as a child how they sometimes had quite
mysterious ways of eating fresh fruit or meat, but for what reason
I did not realise until I had started my career as a dentist. Today
it is obvious to me that they, besides their chewing-problems, also
were uncomfortable with their dentures and in some aspects also
ashamed of their facial aesthetics looking as old persons without
their dentures, regardless their actual age.
Even if dental health has improved greatly during the last decades,
there are still many who wear dentures, often meaning a social
stigma and dental malfunction, social and physiological handicaps.
In contrary to my grandparents situation, it is today possible to
regain the feeling, comfort, and self-esteem of having fixed teeth by
treatment with implant-supported fixed dentures. Some, but not all,
choose this possibility of once again having fixed teeth.
What factors affect this decision-making process? Why do some
choose one treatment option and others another, when the choice
from the professionals point of the view should be quite obvious:
fixed teeth! This issue, including the variations in the patients need,
demand, and utilization, and its gatekeeping factors, has caught my
interest since a few years which has resulted in this thesis, based on
a series of five papers.
The concepts of need and demand are central in studies on dental
care. In the literature, a normative definition is often used1 but pays

15
little attention to the individuals personal comfort and quality of
life. Need and demand for prosthodontic services are difficult to
measure since prosthodontic treatment is highly individual and not
necessarily related to edentulousness.2,3 Need, however defined, does
not always lead to demand for treatment4, depending on a variety
of factors. For a correct assessment of a patients oral health, both
a clinical examination and a dental history obtained in a dialogue
are necessary. Poor oral health has traditionally been regarded
as a component of treatment need, but such need is also socially
constructed and established in the interaction between patient,
society and dentist.5
This interaction also makes demand dependent on available
treatment options from the care provider and from the society. It is
of interest to study how need may be transferred into demand, and
the mechanisms involved in such a process. Studies have shown that
several gate-keeping processes are involved when need is transformed
into demand. The concept gate-keeping has been identified as the
social and psychological processes that transform need into demand,
and demand into utilization.6-8
Many factors are involved in the prosthodontic decision-
making and treatment processes. The patients financial situation is
considered as having a great impact, and the dentists preference is
also a factor of importance in this context.
In the recent decades, treatment with dental implants has been
established as an important component in the range of prosthodontic
treatments. Dental implants have made dramatic improvements of
oral rehabilitation possible for edentulous people, especially for those
unable to adapt to dentures.9 The need and demand for prosthetic
treatment, and especially implant treatment, has changed for many
persons during the last decades, in line with the development of
society. In most Western societies, we are witnessing a shift into
a demand-driven approach in health care.10 The overall desire for
a better oral health related quality of life has become a reality in
prosthetic dentistry, although studies indicate that need as assessed
by dentists overestimates the rehabilitation need, in comparison
with assessment by patients.11-13

16
AIMS

The general aim of this thesis was to evaluate need and demand for
prosthodontic treatment, especially dental implant treatment, but
also to evaluate the importance of gatekeeping factors, and changes
in attitudes towards the implant treatment modality in a longitudinal
study. And finally, by using a qualitative method, to describe the
treated patients process from latent need, over manifest need, all the
way to maintenance after the actual treatment.

Specific aims
The specific aims in this thesis were to:

Set the theoretical ground for the analysis of data from a


longitudinal study by a conceptual analysis of need and
demand for prosthodontics treatment. (Paper I)

Analyse the gate-keeping process between need and demand,


as well as between demand and utilization of dental treatment,
from a theoretical point of view regarding treatment with
dental implants with respect to the patient, to different
treatment options, and to service utilization. (Paper II)

Examine changes in attitudes toward desire for implant


treatment over time in a population of middle aged and older
individuals in Sweden. (Paper III)

By constructing multivariate models investigate possible


factors explaining desire for implant treatment, and possible

17
factors explaining changes in attitudes towards desire for
implant treatment in a population of middle aged and older
individuals in Sweden over a ten year study period. (Paper IV)

Study and describe the process patients missing several or


all teeth go through before treatment with a fixed implant-
supported denture, and to identify the treated patients
experience of changes in oral health related quality of life after
implant treatment, by using the constant comparative method
for grounded theory. (Paper V)

18
MATERIALS AND METHODS

Study I and II
A literature survey was done by applying the PubMed database.
PubMed provides access to bibliographic information which
includes Medline; covering the fields of dentistry medicine, nursing,
veterinary medicine, the health care system and the preclinical
sciences.
Search was continued in MEDLINE and PSYCINFO. The survey
covered the period from 1994 to August 2002 and used the Medical
Subject Heading (MeSH) terms:
1) need OR demand OR attitude OR requirement;
2) prosthodontics OR dental implants) OR dentistry OR
dentists;
3) Combination 1) AND 2)
4) Limits: English, Human

The search strategy resulted in 509 articles of which 147 abstracts


were collected from the articles with an approach to dentistry or
with concentration to conceptual analysis of the MeSH terms in
the first selection group. Further a hand search was made among
the references in these papers for more articles of special interest
resulting in a total of 99 articles used as references.

Study base in study III and IV


Two questionnaire studies were performed by professor Sigvard
Palmqvist, one in 1989 and the other in 1999 among the same
3000 subjects aged 45-69 years in rebro County, Sweden.14,15 The
participants were randomly selected from the official population

19
register. This Swedish county has about 280.000 inhabitants and
was considered average socially and economically at the time of
the studies. 16 A questionnaire was mailed to all subjects, and the
response rate in 1989 was 79.4% (2383 individuals).
Of the original sample, 2708 respondents were found in the
national population register 10 years later, on the basis of the criteria
that they were alive and still had residence in rebro County. In
1999, a new questionnaire was mailed to them.
The number of respondents in the 1999 survey was 1848, yielding
a response rate of 68%. Among those, 1665 (90%) responded also
in the 1989 survey. The individuals who responded both in 1989
and 1999 constituted the panel used in this study and accounted for
56% of the 1989 survey sample.

Non-response in study III and Iv


A non-response analysis has been presented in an earlier study.16
When comparing those who responded only in 1989 with those
participating in both 1989 and 1999, there were significant
differences between the groups. The subjects who responded at both
occasions were, compared with those who responded only in 1989,
younger, had a higher level of education and reported better dental
status, i.e. fewer of them wore removable dentures. Also women
and those who were married or cohabitants had a higher degree of
responding to both questionnaires.
Among those responding both in 1989 and 1999, however, no
significant differences in dental conditions were noted between non-
response groups and the other subjects.16
Internal non-response varied for different questions, which
means different n values for different analyses. There was in 1999 a
relatively high non-response for questions regarding implant desire,
21%. In 1989 the largest internal non-response was seen for the
question regarding the importance of good dental appearance, 14%,
and income, 11%.

Questionnaire in study III and Iv


The questionnaire aimed, among other items, at measuring dental
conditions and opinions regarding dental implants, and at gaining
information about demographics, social structure, oral health

20
related quality of life, desire for various kinds of prosthodontic
treatment, and psychological factors of interest. The variables used
in the questionnaire have been published previously.14 The validity
of answers with regard to dental conditions has been analysed in a
previous study.17
There were questions related to the subjects dental conditions and
desire for implant treatment. Participants missing one tooth or more
and not being replaced, and those completely edentulous with or
without removable denture(s), were in the present study considered
as having a possible treatment need. A hypothetical demand is in
this study described as desire for implant treatment. The following
questions were addressed to catch desire for implant treatment:

You who are missing teeth in one jaw, totally or partially, would you
in general prefer treatment with dental implants, if possible?
(3 alternatives: yes, no, uncertain)

You who are missing some teeth and have a removable partial den-
ture, would you instead prefer treatment with dental implants, if
possible? (3 alternatives: yes, no, uncertain)

You who are missing all your own teeth in one or both jaws, with or
without removable denture(s), would you instead prefer treatment
with dental implants, if possible? (3 alternatives: yes, no, uncertain)

If you who have all your own teeth left would lose one or a few
teeth, what treatment would you prefer? (4 alternatives with im-
plants as one of them)

If you who have all your own teeth left would lose all your teeth
in one jaw, what treatment would you prefer? (4 alternatives with
implants as one of them)

The questions aimed to address respondents with all kind of dental


status.
Those responding that they would choose dental implants were
considered having a possible desire for such treatment which was set
as the dependent variable in the regression models in study IV.

21
The following variables from the questionnaires were used as
independent variables in study IV:

age in years: 3 categories 45-49 years, 50-59 years, 60-69 years


(in 1989)

individual income divided in 8 equidistant groups: <100.000


SEK; 101-150.000 SEK; 151-200.000 SEK; 201-250.000
SEK; 251-300.000 SEK; 301-350.000 SEK; 351-400.000 SEK;
>401.000 SEK.

gender (male; female)

marital status (married and cohabitants; single)


education (low: 9 years, medium: 10-12 years, high: 12
years)

place of residence (city; village or rural)

dental status in 4 categories


I: all teeth left i.e all teeth remaining or all missing teeth
replaced by fixed partial dentures
II: one or several teeth missing i.e one or several
teeth missing and not replaced by fixed partial dentures
III: removable denture i.e. wearing removable partial
denture(s) and not edentulous in any jaw
IV: totally edentulous in one or both jaws i.e. edentulous
in one or both jaws and wearing or not wearing denture

patient at dental care delivery system (private practice; public


dental health system)

There were also two attitudinal scales in 7 steps which were


dichotomized in the analysis18:

importance of dental function (unimportant; important)

importance of good dental appearance (unimportant; im-


portant)

Internal non-response varied for different questions.

22
The two questionnaires were identical except for a few new
questions added in 1999 about the number of lost teeth, prosthodontic
treatments, and various complications having occurred since the
previous study. Written information about costs and treatment
procedures for implants was included in both questionnaires. The
information included estimated costs for a complete arch fixed
implant-supported prosthesis in the maxilla, for a single tooth
implant restoration, and for a complete upper and lower denture.
The costs for implant treatment were considerable, although such
treatment was subsidized by the national dental insurance system in
Sweden. For example, the treatment costs for a complete arch fixed
implant-supported prosthesis was approximately 5 times higher
than for conventional removable dentures both 1989 and 1999.
The total panel was divided in two groups, those with and those
without changes in dental conditions during this period, to evaluate
their need for implant treatment.

Study v - Qualitative method


The constant comparative method for grounded theory, originally
described by Glaser & Strauss (Modified grounded theory) was
used in collecting and analysing data.19,20 This qualitative method
aims at generating concepts, models, and theories, grounded in
empirical data. Grounded theory aims to develop understanding
and interpretation of the individuals description of experiences
rather than to try to seek the objective truth. The basic principles
of grounded theory include concurrent sampling and analysis,
constant comparisons, theoretical sensitivity, and saturation.
Saturation is reached when new interviews do not bring additional
information into the categories devised in the earlier interviews.21
Grounded theory is one out of approximately thirty qualitative
research methods and includes both induction and deduction, which
means constructing a hypothesis from the obtained data, making
conclusions with a starting-point from the hypothesis. Induction is a
main part in grounded theory, one of the differences to quantitative
research. Criteria for judging the quality of a grounded theory study
22
is described in paper V.
One assumption in qualitative research is that data are brought
forward in interaction between researcher and informant.21

23
Therefore, the relationship between these two subjects should be
paid attention to, because of its importance for the results. This
reflexivity includes that the researcher must identify preconceptions
which might bias the interview.23

Study group in study v


Ten informants (six women and four men; mean age 69 years, range
54-84 years) participated in the study. The informants were patients
at the Specialisttandvrden Kaniken, Folktandvrden (Specialist
Dental Care Kaniken, Public Dental Health Services), Uppsala,
Sweden, according to well-known and accepted procedures.24 The
patients were strategically selected from the register at the clinic on
the basis of gender, age, and place of residence and treated by other
dentists than the authors.

Procedure study v
Each subject was informed by letter about the study and asked if
they were willing to participate. Written and verbal information
concerning aim and procedure of the study was given to all subjects.
After a written consent, time for a taped interview was scheduled
with each individual.

Approach Study v
An open, taped interview was conducted with each subject. An
interview guide was used, closely described in paper V.
The interviewer was a prosthodontist (first author paper V)
without knowledge of the informants and without involvement
in their treatment. Each question theme gave the opportunity to a
broader discussion, as for example a variety of potential gatekeepers.
Data collection and analysis were conducted after each interview
and continued until new interviews did not provide additional
information. This saturation was reached after 10 informants.

Statistical methods in study iii and iv


Statistical significance in study III was determined through Pearson
chi-square test with p<0.05 as significance level. For dichotomous
responses, Odds Ratios (OR) with 95% confidence intervals were
also calculated.

24
Three different logistic regression models were used in study
IV for analyses of the responses for those participating in 1989,
in 1999, and for analysis of the differences in response between
those who participated both in 1989 and 1999.25 The effect of
independent variables was expressed as odds ratios. Nagelkerke
(pseudo) R-square, classification plots, and correctly predicted cases
were calculated for determination of goodness of fit of the models.
The same model was used for analysis of non-responders. Frequency
distributions were calculated for the various measures. The statistical
significance of differences was determined through Pearson chi-
square test with p<0.05 as significance level. All calculations were
done in SPSS 11.0.

Data analysis study v


The interviews were transcribed verbatim and analysed in open, axial
and selective coding processes,19,20 described in paper V, resulting
in the identification of a core category, central in the collected data
and related to subcategories.

Ethical aspects
The study design of paper V was supported by the Research Ethics
Board at Uppsala University, Sweden. Requirements concerning
informed consent and confidentially were promised and secured.

25
RESULTS

Study I: What is Oral Rehabilitation Need?


A conceptual analysis of need and demand for
prosthodontic treatment.
The concept of need belongs to the social sciences. There is no
generally accepted method for measuring human welfare, because
of the difficulties to define human needs. Moreover, human needs
have been considered to be relative rather than absolute.26 If need is
defined by professionals, this simply puts one subjective opinion
the professionals against another subjective opinion: the patients.
In a conflict situation, the strongest party prevails, which usually
is the profession. A subjectivist and relativist conception of need
therefore inevitably gives a disadvantage to those who are too weak,
too old, or too sick to express their own needs, precisely those
persons whose needs the professional should try to meet.
There are, though, theories suggesting that objective needs do
exist and that the most important attributes are physical health and
autonomy.26 The autonomy is impaired when there is a deficit of
three attributes: mental health, cognitive skills, and opportunities to
engage in social participation.
There are other simpler attempts to define objective needs, and
one theory suggests that there is a hierarchy of needs, where the
most basic needs must be met before needs higher in the hierarchy
can be actualized.27 This implies that health needs must thus be
satisfied before autonomy, since the need for health is a condition
for subsistence.
A taxonomy of need was presented in 1972 by Bradshaw28 where
he divided need into four separate definitions:

26
Normative need is that which the expert or professional defines as
need in any given situation. A desirable standard is decided and
compared to actual circumstances.

Felt need is equated with want expressed after self-assessment by the


individual or the population. In a study of prosthodontic treatment
need, it was shown that subjective need without a normative need
is rare.11 Normative and subjective need coincided only in one third
of the studied treatments. Normative need was significantly higher.
The discrepancy between normative need and subjective need is in
accordance with other reports.29-32

Expressed need is equivalent to demand i.e. felt need turned into


action.28

Comparative need is assessed by studying the characteristics


of a population using a service. If there are people with similar
characteristics not receiving service, they are in need. This definition
has been used to assess needs both of individuals and areas.

Sheiham and Spencer have analyzed normative need as being a


commonly used type of need assessment in dental health planning.33
However, by using normative need diseases are identified without
considering the subjective perception of the patient and its relevance
to the disease-oriented or biomedical approach. Sheiham and
Spencer33 find that there are four major shortcomings of normative
need:

First, professional judgements are neither free of individual


valuation nor objective. There is intra-examiner and inter-examiner
variability in judgement and decision-making.16 Variables such as
age, practice beliefs, and price competition in the marketplace have
effect on treatment.34 For example, many young dentists in Sweden
today have little or no experience in complete denture treatment
unlike general practitioners a few decades ago, which could lead to
avoidance of proposing such treatment options because of lack of
experience.35

27
Second, the normative need defined by dentists does not necessarily
correspond to the experienced need of the patient. Patient satisfaction
is not always related to the clinical assessment36 and for example,
lack of posterior teeth leads to demand for prosthodontic treatment
only in some situations. Both type and quality of the treatment is
important, but not decisive for patient satisfaction,37 although there
is a relationship between health-related quality of life measures and
clinical oral indicators.38

Third, there is not always correspondence between political and


professional need assessment. An example can be found in the
Swedish National Dental Health Insurance System a few years ago,
where persons aged 65 years and above received a highly subsidised
part of the total cost for prosthodontic treatment, irrespectively
of their dental health or paying ability. This was a purely political
decision without professional support.

Fourth and finally, there are not always resources to meet a normative
need. All dental needs cannot be met. The need definitions depend
on realistic treatment possibilities. Economic subsidies make new
treatments available, e.g. dental implants.

28
Study II: Need becoming demand, demand becoming
utilization. Gatekeeping processes from a theoretical
point of view.
Need does not always lead to demand for treatment, nor to
utilization, depending on the gate-keeping processes between need
and demand and between demand and utilization. The concept
gate-keeping refers in this context to the social and psychological
processes that transform need into demand, and demand into
utilization.6-8 It implies that they are complex processes that can
render great differences between demand and actual utilization. It is
not possible to estimate patients need for prosthodontic care, since
there is no objective need.
The process between need and demand is influenced by several
factors identified as barriers or gatekeepers.39 Need can be regarded as
latent or manifest. Becoming aware of a latent need, which eventually
becomes manifest, is a multifactorial process which involves:

oral health and edentulism


quality of life and perception of need
psychological factors (e.g. dental anxiety state)
health beliefs (attitudes, values, and behaviour)
social structure (education, occupation, and ethnicity)
demographics (age, gender, marital status, and income).

Edentulous patients with denture problems do not necessarily


translate such concerns into demand for treatment.3 Most
edentulous individuals adapt to wearing complete dentures, but for
some, impaired oral health resulting in losing the natural dentition
or only a part of it is a serious life event and has been compared
with other stressful events such as divorces or retirement.40 It can
be experienced as a mutilation, a serious change of life.41 A greater
concern about demand is a consequence of the realization that there
is no objective need. Still, in most cases demand must be recognized
as the result of an actual need.
A missing upper anterior tooth is a strong incentive for demanding
treatment, while loss of a posterior tooth usually is not. Position and
number of teeth have a definite impact on need for prosthodontic
treatment.42,43

29
There are contradictory results when replacing lost teeth with
removable dentures, indicating that demand is dependent on the
patients opinion.44 It has been shown that about 25-50% of the
individuals who had removable dentures seldom or never use them.45
Cost factors seem to play an important role also here, and there is a
higher probability for low dental care utilization among those who
consider dental care as expensive compared to those who state no
problem with cost.45
Four main groups of psychosocial factors have been identified
to act as gatekeeping barriers between need and demand: a) dental
anxiety states, b) perception of need, c) financial costs, and d) lack
of access.46 The two latter factors mainly belong to the gate-keeping
process between demand and utilization. Concern about oral health
has been reported as significantly predicting perceived treatment
need.47 Individuals who regularly attend a dental office are likely to
have a much higher perceived need than irregular attendees. Barriers
such as fear of pain and anxiety, cost and long waiting time have
been found to have little influence, but the dentists recommendation
was important.11,48
Dental anxiety is one of the major parts in the psychological barrier
between need and demand. It appears to be mostly dependent on
experiences from youth49 but might sometimes be used as a pretext
not to fulfil a demand because of a poor economic situation.
Healthy teeth are important to most people regardless of age.50,51
But dissatisfaction with appearance has also been found to be a
major reason for transforming need into demand.52 New adhesive
techniques with veneers and all-ceramic restorations require minimal
tooth-preparation. The increasing commercialization of the body
image and the change in social normative standards have resulted in
subjective demand for cosmetic dental care where dentists sometime
may have difficulty identifying patients need. However, demand for
cosmetic dental care varies in different age groups and in different
cultures. Expectations of dental health status and dental care may
vary between individuals with different social norms and cultural
traditions.53,54 Edentulism following dental disease is considered as
a most likely development and a natural part of life in some ethnic
and social groups.

30
There seems to be a gender variation in the social impact of oral
health on perceived quality of life. Women are reported to assess
oral health as more important while men rank chewing ability
higher.41,55-57 Another study show that elderly females are less
satisfied with conventional dentures than elderly males with regards
to aesthetics and ability to chew, but equally satisfied with implant
overdentures.58 But there are also reports indicating contradictory
results regarding need for prosthodontic services between men and
women.41,59,60
Edentulism may be correlated with age and gender and is also
more prevalent in rural areas, while there seems to be a greater
demand for treatment in more densely populated areas.62,61 Factors
such as ethnicity, cultural attitudes, and standard of living have an
impact on need and attitudes toward dental care where e.g. citizens
in urban Western societies have a much higher level of demand for
treatment than patients in less developed countries.62 Individuals
with a high level of education, prominent occupation and high
income have a lower barrier compared with those who have a low
level of education and a reduced financial capacity. It is likely that the
global internationalization and growing prosperity may change the
need for dental treatment, and through changes in the gate-keeping
processes, new demands could be developed. Moreover, technical
achievements in the field of prosthetic dentistry may also contribute
to a change in demand among individuals.
The process between demand and utilization is closely correlated
to social and economic factors, which can act as inhibitors or
prohibitors in the process between a demand and utilization of this
demand. Gate-keeping mechanisms have been used to control costs
of care and to promote cooperation between different groups of care
providers.39
Originating from models of health service utilization, explanatory
models for utilization of dental care have been put forward,63,64
described in paper II.

31
Study III: Changes in attitudes toward desire for implant
treatment. A longitudinal study of a middle-aged and older
Swedish population.
The main result was a dramatic escalation in interest for implant
treatment during this period.
In 1999 almost all (94%) of the cohort expressed desire for
implant treatment. Ninety-two percent of those who did not express
a desire for implants in the first questionnaire had changed their
mind 10 years later. There was a very high probability (OR=3,9)
that participants who wanted implant treatment in 1989 held the
same opinion 10 years later.
There were age group differences among those who desired
implant treatment in 1989. Reported desire for implant treatment
decreased with higher age. There were no significant age differences
in 1999 since almost all desired implants. The results are shown in
the tables of paper III.
Forty-seven of the 111 edentulous individuals (7% of the panel),
answered the questions regarding desire for implant treatment.
Two thirds of those (32 individuals) reported a desire for implant
treatment at the time of the second questionnaire study. Of those
who were edentulous and not interested in having implant treatment
in 1989, 38% changed their opinion and reported an affirmative
attitude in the study 10 years later.
The increase in desire for implant treatment was similar between
those who reported changes and those without changes in dental
conditions over the 10 year period.
Those having a possible treatment need, missing one tooth or
more, and with or without removable dentures had a significant
increase in desire for implant treatment between 1989 and 1999,
while there was no significant increase among those without such
a need.
Cost was the major reason for not choosing implants among
subjects reporting one or a few teeth missing and not replaced
and those with removable denture(s). No significant changes were
observed from 1989 to 1999.

32
Study Iv: Factors explaining desire for therapy with
dental implants. An analysis of the results from a
longitudinal study.
Older people, non-city residents, and those with one or several
missing and un-replaced teeth, changed desire for implant treatment
between the study years. Effects of age, residence, better dental status,
and concern for a good dental appearance disappeared during the
ten year study period. Those edentulous and those with removable
dentures (pseudo R2 0.17), expressed lower desire than those with all
teeth remaining, or with only one or a few teeth missing (pseudo R2
0.24) in 1989. High income significantly increased the probability to
desire implant treatment for the study panel at both study occasions
(p = 0.016 resp. 0.034).
A logistic regression model was constructed with the dependent
variable respondents stating a desire, in contrast to those without
a desire for implant treatment in 1989. It showed a significantly
higher probability to desire implant treatment for the independent
variables higher income, younger age, better dental status, urban
living, and concern for a good dental appearance. Income had the
strongest association with a desire for implant treatment. There was
a 7% higher probability to desire implant treatment between each of
the 8 equidistant groups giving a total of a 56% higher probability
to desire implant treatment for those with the highest level of income
than for those with the lowest level.
The association between a desire for implant treatment and dental
status was however not expected. Those with a higher objective
need, i.e. those with removable dentures and those being edentulous,
had a lower probability to desire implant treatment than all other
categories of dental status.
Another logistic regression model was constructed for the
population responding in 1999 in the same manner with the
dependent variable respondents desiring implant treatment in
contrast to others. High income, still, increased the probability to
desire implant treatment for the total population. There was also
no change in associations as to dental status. However, there was a
change in desire for implant treatment for those wearing removable
partial dentures or being edentulous in one or both jaws. For this
subgroup the independent variables dental care delivery system and

33
education level showed a significantly higher probability to desire
implant treatment for those attending private practise and for those
with medium education level.
The final logistic regression model was done with the responses
to the question about desire for implant treatment from 1989 in
contrast to the responses to the same question in 1999. Young age,
urban living and better dental status showed a higher probability for
a desire for implant treatment in 1989 than in 1999.

34
Study v: A grounded theory on importants factors involved
in the treated patients decision-making process for implant
therapy.
The emerging core category was the participants experiences from
social stigma to exhilaration. A great improvement in oral health
related quality of life was stated.
The informants stories illuminate the journey from deteriorated
dental health with pain and lowered self-esteem which resulted in
social withdrawal e.g social stigma, to the decision of going through
with implants treatment to feelings of gratitude and feelings of
becoming the person one once was. This process ended up in a more
realistic perspective that their new life with dental implants indeed
was very good and meant an end of their social stigma. However
the process had some gatekeepers, such as fear of pain, including
the risk of having problems afterwards with the implants, and costs.
The dentists opinion and suggestions was the most decisive part in
the decision making process and the trust in the dentist and his/her
dental team was crucial for the decision to undergo treatment, and
for the whole experience with the treatment.
All of the informants had considered the possibility of implant
treatment for some time. Some made their decision after initially
having discussed it within the family, others because of comments
from acquaintances, advertisements, or because of the lack of taste
when eating which was reported by all, and the feeling of loose
dentures. It was obvious that the trust in the dentist and his/her
skills was a very important part in the decision making process
but perhaps an even more important part was the possibility to
discuss the treatment options with the dentist, especially having the
chance of discussing their individual need for treatment. Some of
the informants changed dentist during this process because of lack
of trust.
Only two gatekeeping factors were mentioned by the informants,
cost and dental anxiety. Cost was considered as a gatekeeping factor
of little importance. All but one of the informants said that they
would desire and demand this treatment at almost any cost and were
prepared to take a bank loan, if necessary. A correct estimation of
cost together with a pronounced trust in the dentist seemed to be of
importance in the decision process.

35
The journey from social stigma to exhilaration are discussed in
paper V and could be divided into four different parts:

First:
becoming an unsecure person
Experience decreasingly worsened oral health
The participants described a history of many years of deteriorated
oral health causing physical pain, infections and discomfort and it
also caused difficulties with for example chewing, fear of cleaning
their teeth because of the risk of losing teeth.

Living in pain and anxiety


Finally the participants lost so many teeth or all teeth that they
had to wear a denture which was even worse than the deteriorated
oral health. The dentures caused physical pain and sourness and
were connected with feelings of shame and a variety of practical
problems. The social consequences were massive for the participants
and they did not tell anybody that they had a denture except to their
closest family.
A sense of powerlessness was reported by participants. They
could not do anything about their ability to adapt to their denture.

Second:
becoming a determined person
Desire for a better solution turn in to demand
The participants described how they finally felt a desire for a better
solution of their dental problems than wearing a denture. The life
situation with the denture was unacceptable with all the reported
difficulties. The participants described the cost for dental implants
as a gatekeeping factor of little importance in the process of deciding
whether to have or not to have the implant treatment.

Having trust in the dentist


It was of great importance for the participants to find a dentist they
could really trust in both regarding medical skills and as a person.
The feeling of being involved in the treatment was important. The
participants knew about dental implant treatment since long through
media, from dentists or relatives, or by advertisements, but their

36
definite decision was made after discussion with their family and
ultimately with their dentist, where trust in the dentist was decisive.
Dental anxiety for the treatment was seen as a minor problem
which also was considered dependent on their trust in the dentist.

Going through with the treatment


The participants were very satisfied with the result of the implant
treatment, feeling restored in oral function and aesthetics and giving
a regained self-confidence and self-esteem. Some of the participants
put the oral-facial aesthetics forward as the most important over-all
factor for self-confidence. The treatment outcome was described by
all the informants as a substantial improvement in oral comfort and
in quality of life even though some of the participants described pain
after the implant operation and some had experienced difficulties
with implants which did not integrate, giving prolonged treatment
and re-operations. No-one described this as having any negative
influence on their opinion of the treatment, which they all considered
as a success. Those with the experience of disintegrated implants did
all blame themselves of causing the unsuccessful osseointegration of
the implants. No one considered this as a result of poor management
from the dentist.

Third:
becoming the person i once was
Being free from the prison of pain and social stigma
The totally dominant opinion was the feeling that implant-supported
fixed partial dentures felt better than a conventional fixed partial
denture and was comparable to their own natural teeth. It felt
and functioned physically as their own natural teeth. The sense of
regained security was very common.
For those who had had recurrent infections, loose teeth, or badly
functioning dentures, the fixed implant supported denture gave the
patients the feeling of good dental status and of being orally healthy
for the first time for many years. They did not have to visit their
dentist as often as before and they were pain-free. They felt orally
healthy.
A fixed implant-supported denture was compared with having
own natural teeth also when it came to aesthetics.

37
Having feelings of gratitude
All the participants spontaneously expressed gratitude to the dentist
and his/hers staff. The trust in the dentist and the skills of the staff
was pointed out by all the informants in almost every aspect of the
implant treatment.

Forth:
being caught by a more realistic perspective
Being hit by the pale cast of thought
After a while after the participants treatment and their feelings of
becoming the person they once was and feelings of gratitude they
started to be aware of minor negative side effects of the implants.
Most of the participants found it difficult to keep up optimal dental
hygiene. Those informants who received a fixed implant supported
denture in the upper jaw reported difficulties in speech. This seemed
to diminish over time, though.

38
DISCUSSION

Methodological discussion
This thesis is based on a series of articles aiming to analyse how to
estimate individuals need and demand for prosthodontics, especially
with dental implants, and its gatekeeping processes. The thesis also
aims to evaluate changes in attitudes and relevant factors regarding
these issues from two questionnaires in a longitudinal study. As a part
of this exploration an interview study was also performed, following
the grounded theory concept, describing the treated patients.
The conceptual analysis of need and demand and utilization in
study I and II was started by a literature search from PubMed and
resulted in articles both from dentistry and from other sciences. A
supplementary search was conducted 2011 giving some articles with
relevance to this thesis.
The population selection in the questionnaire studies III and IV
could of course be a matter of discussion. The material was collected
by others (professor Sigvard Palmqvist et al) and here a secondary
analysis is done. The 3.000 participants were over the age of 45 and
randomly selected from the population register. The response rate
for those responding at both occasions was 56% of the 1989 total
survey which must be considered adequate in a longitudinal study
stretching over a decade. As the aim was to investigate changes in
attitudes over time this would implicate that the non-response rate
should be less important because it was the same individuals at both
occasions. The changes in attitudes are principally intra-individual,
giving strength to the result.
Comparing those who responded only in 1989 with those
participating in both 1989 and 1999, gave some significant

39
differences.16 Those who responded at both occasions were younger,
had a higher level of education and reported better dental status.
Internal non-response varied though for different questions. Still, the
material was considered relevant and reliable for the present studies.
The patients interviewed in study V was selected from the register
of a clinic with specialists in prosthodontics to which the patients had
been referred. The informants were selected on the basis of gender,
age, and place of residence from both cities and rural areas and
they were recently treated with dental implants. No consideration
was paid to personal factors as health, level of education, dental
experience, or socioeconomic factors in this selection process.
Saturation was reached after interviewing 10 informants giving
adequate variation regarding the factors not included in the selection
process, which is desirable in qualitative studies.

validity
The questionnaires in study III and IV included questions about dental
condition. The answers showed high agreement in a validation study
performed earlier among the subjects in the 1989 questionnaire when
comparing self-reported dental status and the result from a clinical
examination.17 This is in accordance with another validation study
on congruence between clinical findings and patients self-reported
oral status.65 Attitudinal questions can of course not be validated,
lacking comparison data.
When discussing the design of a qualitative study you consider
both internal and external validity. The sampling procedure with data
collection until saturation is reached is considered as being closely
related to internal validity.66 The emerging categories, describing
trust and confidence in the dentist, were all grounded in data and
along with the quotations intended to show the trustworthiness
of our study and the internal validity. External validity concerns
transferability to a new context.66 My opinion is that the results from
this study could be transferable to other groups treated with implant-
supported fixed dental prostheses with similar characteristics to our
study group. As stated in study III in this series of papers, there
was a huge increase in interest for implant treatment from 1989 to
1999. Almost all (94%) of the study population expressed desire for
implant treatment in 1999, one of the main findings here.

40
Strengths and weaknesses
There are some aspects which should be considered in our studies.
The conceptual analysis is based on articles from PubMed but only in
English and Swedish. This gives a risk of failing to include opinions
and studies of relevance from other countries, or with other cultural
and socio-economic background. On the other hand, a hand search
was done in the references in these articles giving little to add.
Data for the questionnaire studies were collected in 1989
respectively in 1999 and it could be questioned if the results are
applicable today. My opinion is though that the results from
these questionnaires still are relevant. At the time for the second
questionnaire, a vast majority expressed their opinion that they
would prefer implant treatment, in difference to the result at the
time for the first questionnaire. As far as I know there has been little
change in social priorities, or attitudes towards implant treatment
since, meaning that a change back to less desire for implant treatment
is unlikely. A recent Austrian longitudinal study 67 showed a higher
degree of public awareness of dental implant treatment as a treatment
option compared to 2003. The implant treatment acceptance rate in
that study did not change during the study period. This indicates a
stable level of desire for implant treatment during the last decade,
however on a clearly lower level than in our study.
Selection of informants to qualitative studies performed according
to grounded theory should be discussed. The patients in our study
had been treated with dental implants and had been referred to a
specialist clinic, meaning that they had passed gatekeepers as initial
discussion of cost, and they had also gone through the decision-
making process, and still demanded implant treatment. We did not,
though, make any distinctions for other factors as illnesses, economy,
or education except for age and urban/rural living. The intention
for this study was not to study needy patients without demand for
implant treatment which of course would be of great interest, but
out of scope for this study.

Statistical Methods
In the third study, statistical significance was determined through
Pearsons chi-square test with P<.05. For dichotomous responses
odd ratios with 95% confidence intervals were calculated.

41
Three different logistic models were used in study 4 for those
participating in 1989, in 1999, and for the differences in response
between those who participated both in 1989 and 1999. A clear
strength of this study is the longitudinal design which gives a higher
credibility regarding changes in attitudes.

Factual discussion
The main purpose was to study factors behind the development of
need and demand for dental implant treatment from the patients
point of view, and attitudes towards this treatment option. Some
studies have previously described factors involved in dentists
decision-making process, but very few have studied the patients
part of this process.16,32,34,35
A main finding in this thesis is the importance of the emancipatory
perspective in the dentist-patient relation, the importance to a
dialogue discussion and participation in the decision-making
process. This corresponds well to the finding in study V, that the
most important factor was trust in the dentist and his/her staff.
The relationship between dentist and patient is crucial in order
to give opportunity for latent needs to develop into manifest needs
and demands, and eventually to turn it into actual utilization. The
gatekeeping factors seem to diminish in importance when there is trust
in the dentist. How patients assess the outcome of their treatment
seems to be dependent on a positive relationship between dentist
and patient. The importance of this right to actively participate in
decision-making regarding the management of their tooth loss is
also verified in another study as an increasing expectation.68
Another finding is the very large escalation into having
a hypothetical demand for implant treatment shown in the
longitudinal study in paper III. Another study from Norway from
the same period as our study, though not longitudinal, indicates a
somewhat lower awareness of implant treatment as an treatment
option.69 As mentioned above there are some recent longitudinal
Austrian studies also showing a somewhat lower general awareness
of dental implant treatment.70 The reason for the higher levels in our
study could be that the participants got information through the
first questionnaire and this information was boosted in the second
questionnaire. Another reason could be a higher degree of attention

42
in Swedish media towards dental implant treatment while much
of the development of this treatment option and the mechanisms
behind osseointegration was occured in Sweden at this time.

need and demand and utilization


The idea of objective need, a normative need defined by professionals,
has little support in todays literature.29-33 A taxonomy of need was
presented in 1972 by Bradshaw 28 where he divided need into four
separate definitions:
Normative need, Felt need, Expressed need, and Comparative need.
Normative need in this taxonomy simply puts one subjective opinion
the professionals in relation to another subjective opinion the
patients.
Sheiham and Spencer found four major shortcomings of normative
need:
First, professional judgements are neither free of individual valuation
nor objective.
Second, the normative need defined by dentists does not necessarily
correspond to the experienced need of the patient.
Third, there is not always correspondence between political and
professional need assessment.
Fourth, there are not always resources to meet a normative need. All
dental needs cannot be met. The need definitions depend on realistic
treatment possibilities. Economic subsidies make new treatments
available, e.g. dental implants. Need perceptions and demand grow
rapidly which points to another conception of need, the so called
emancipatory need.
The professionals first commitment must be to discern latent
needs that are relevant but may be subconscious or unexpressed.5
The processes between need and demand, and between demand and
utilization are influenced by several factors, identified as barriers or
gatekeepers as already discussed.39 Our qualitative study on treated
patients indicate that trust in the dentist and his/her staff seemed to
diminish most gatekeeping factors. The financial aspects involved in
the process related to need and demand for prosthodontic treatment
should not be underestimated, and it is well known that edentulism
is more prevalent among individuals with low or no income. The
treated patients in our qualitative study did not put economy

43
forward as a gatekeeper, but the respondents in the questionnaire
studies had economy as the main gatekeeping factor.
Need and demand for prosthodontic treatment among the
partially edentulous individuals are difficult to estimate.
There are contradictory results when replacing lost teeth with
removable dentures, indicating that demand is dependent on the
patients opinion.44 and perhaps not so much on the professional
opinion. It has been shown that about 25-50% of the individuals
who had removable dentures seldom or never use them,45 indicating
that the inconvenience of wearing dentures sometimes outdoes their
gain of having a removable denture.
Prosthodontic treatments are often associated with a high cost for
the patient. Supplier-induced demand and dental insurance schemes
are factors of interest in that respect.71-74
Still, two observations here remain: Trust in the dentist is essential,
and needs can change rapidly.

Changes in attitudes towards dental implant treatment


The strong and significant change in desire for implant treatment
for the entire panel, as well as for different subgroups, may at
least partially be explained by increased knowledge about implant
treatment. It is likely that most individuals had a better knowledge
about dental implants in 1999 compared with the situation 10 years
earlier, due to newspaper articles and information provided by the
dentists and maybe also as a learning effect of the questionnaire.
The Norwegian study showed that news media like newspaper and
TV/radio, together with personal communications, were the most
frequently indicated sources of information.69 The longitudinal
Austrian study showed though that the dentist was the main source
of patient information.72
The overall desire for a better oral health related quality of life
has become a reality in dentistry. Further, there is evidence that a high
interest in aesthetic dentistry and tooth bleeching among patients
could be related to tv-commercials on new cosmetic treatment
options.75 This could be related also to innovations that focus on
consumption, which could promote an increased interest especially
among the young, wealthy and well educated.76

44
The results from the study indicate a great increase in desire
for implant treatment for those with a possible treatment need.
This could support the assumption that an individuals need may
turn from latent to manifest, when treatment options having been
unrealistic become available. New desires will emerge.
Among the 111 individuals who reported having no natural
teeth, with or without removable dentures, the response rate was
only 42%. The number of respondents was, however, sufficient
to permit some conclusions; 47 persons allowing a precision of
about 15%. This rather small group had a lower increase in desire,
compared to the total panel. This could be the effect of several
socioeconomic gatekeeping processes.73 Individuals with short
education and low income tend to have poorer dental status, in
part because of poor finances.
The results from the present study indicate that several
edentulous individuals still are not able to afford implant-supported
prosthodontics. It is obvious that although Sweden has a general dental
insurance system, there are several orally handicapped individuals
who are not able to benefit from implants due to high costs.
Another possible explanation could be that older individuals
who are accustomed to wear dentures have no or minor interest in
implant treatment.77 Studies indicate that a large number of patients
(65-90%) are satisfied with the functional aspects of their dentures,
often in spite of technical imperfections identified by dentists.78,79
There is also evidence that removable prostheses are more preferred
among those who have few or no remaining teeth, compared with
those who have only one or a few missing teeth.80 It appears that
those with a removable prosthesis have a lower expectation and
demand for oral function and aesthetics, and that satisfaction with
removable prosthesis may be a rationalization, in which an attitude
could develop through behavioral change.47,81 A Canadian study
shows gender differences where elderly females are less satisfied with
conventional dentures than elderly males with regards to aesthetics
and ability to chew but equally satisfied with implant overdentures.58

45
Factors explaining desire for therapy with dental implants
The longitudinal study showed that older people, those living in
village or rural areas in comparison, and those with one or several
teeth missing and not replaced, had changed their mind into having
desire for implant treatment ten years later.
Income and dental status also had a significant impact on the
probability to have a desire for implant treatment.
Dental status had a significant impact on expressed desire at
both study occasions. Somewhat surprising was that those with a
higher objective need, i.e. those with removable dentures and
those being edentulous in one or both jaws, had a lower desire for
implant treatment in contrast to others. It seems obvious from the
results of the present study, that edentulous patients with removable
dentures do not necessarily translate that condition into a desire for
implant treatment, which is in accordance with previous studies.82
Participants missing one tooth or more not being replaced, and those
completely edentulous with or without removable denture(s), were
in this study considered as having a possible treatment need. It was
not possible to distinguish between the absence of a front tooth or a
molar on the basis of the information from the questionnaires. If this
distinction had been possible the results could have been even more
obvious since participants missing a front tooth probably desire a
replacement more.
Objective need is less associated with dental care utilisation
than subjective need as described in paper IV. This result is also
well in accordance with the observations that there usually are great
differences between providers and patients assessments of quality
of life, where patients usually regard their quality of life as better
than the providers do.13 Those who need implant treatment the
most, when assessed by dentists, do not desire implant treatment as
much as those with all teeth remaining or with one or a few teeth
missing. Presence of own teeth is a significant predictor for dental
care utilisation.83

gatekeepers from the questionnaires


In the questionnaires, there were also questions aiming at evaluating
reasons for not choosing implant treatment. The structure of the
gatekeeping processes determining an individuals choice has been

46
discussed earlier in this thesis. Such processes are multifactorial.
For example, there can be combinations of problems of oral health
and quality of life, psychological factors and health beliefs, social
structure and demographics, and economic factors.
Cost was the major reason for not desiring implant treatment,
but also the percentage figures for scared of surgery and scared
of un-known side-effects had slightly increased over the 10-year
period. A study of Walton et al. showed that the most common
reason for refusing free of charge treatment with implant-supported
mandibular dentures was concern about surgical risks.79 Dental
anxiety appears to be an important gatekeeper in dentistry among
many patients.43 A recently published study from the UK showed
that fear and anxiety, related to the pain of surgery, complications
of the procedure and immediate post-surgical denture use, was
one of the main reasons why elderly patients who were currently
dissatisfied with conventional dentures decline implant treatment.84
Women were in our study more concerned about implant surgery
and the risk of unknown side effects of implants. Such a gender
variation has been discussed in other prosthodontic studies.85,86
The rather small edentulous group in this study had a lower
increase in desire compared to the total panel. This could be the
effect of several socioeconomic gate-keeping processes.87 Many
edentulous individuals have low income and it is likely that some
do not consider treatments they know they cannot afford even if
their oral health-related quality of life most likely would benefit
significantly from the use of dental implants.88 In such situations,
the desire for treatment does not change from latent to manifest.
Other reasons could be fear for dental treatment and worry about
surgical treatments but it could also be signs of that people really
are more satisfied with their prostheses than the profession would
consider.79,84
Cost, together with dental status, is a well-known barrier in
the gatekeeping behind utilization of dental care, especially for
fixed prosthodontic services.43,89,90 Persons with low income have
a lower level of utilization and spend less money on dental care
compared with individuals with higher income.85 This, although
to a lesser extent, also holds in subsidized systems.86 The National
Dental Insurance System in Sweden was introduced in 1973 and

47
has changed a number of times since. The relative cost for implant
treatment within the Swedish subsidised dental health care system
did not decrease during the ten year study period, but rather
increased to some extent. Income did not change as an important
gatekeeping factor between the two questionnaire study occasions.
Another study indicates that cost is estimated as too high by three-
quarters of the interviewees.66 They were, though, uninformed of
the actual cost. Yet another study showed that patients who had
undergone implant treatment deemed the cost to be reasonable to a
large extent.91

Trust in the dentist


The patients trust and confidence in the dentist and his/her staff
is very important in the process of transforming desire for dental
implant treatment into a manifest demand, and in making it more
likely for the patients to become satisfied with the treatment result
regardless of complications. Mutual discussions in the treatment
planning process, primarily good pre-treatment information, and
accurate cost estimation were reasons for developing this trust and
confidence. Experienced complications like disintegrated implants
were not considered as a result of bad management from the dentist.
Instead, the participants put the blame on themselves.
None of the two identified gatekeeping factors, cost, and dental
anxiety, were reported as important for the decision of getting
implant treatment by the treated patients in study V.
A great improvement/recovery in oral health related quality of
life was stated in terms of regaining the feeling of self-esteem and
being secured in social relations. The ability of sensing different food
tastes was also regained after implant treatment and the perception
of the implant supported fixed denture was the same as of own
natural teeth.
Both a study of Trulsson (Hallberg) et al,41 and the present study
show how informants with removable dentures developed avoiding
strategies in order to ensure that no one would notice the denture.
In order to manage uncertainty, they often avoided social contacts,
especially when eating. These avoidance strategies contributed to
restricted social participation and a change in self-image.

48
The grounded theory study revealed the importance of the patients
trust in the dentist as the core category and main finding. This trust
seems to be vital for the patients choice, acceptance and completion
of the treatment, also making the patient more likely to be satisfied
with the treatment result. This expression of trust in the dentist
was common even from those informants who had experienced
complications. There is a possibility that the results from this study
could be applicable to a wider context. However, patients who were
unable to be successfully treated with fixed implant prosthesis were
not included, nor were informants who had to pay the full cost of
the treatment.
The result in this study differs from the results of another
qualitative study that showed that patients with chronic periodontitis
stated that they had to depend on the care provider independently,
whether they agreed to the treatment plan or not. The patients also
had difficulties to foresee the result of the treatment.92 A conclusion
from that study was the importance of giving thorough information
about the planned treatment and to give much attention to the
patients individual needs. In our study, the informants described
information regarding treatment and costs as very good, and also
that the thorough individual preparation before treatment gave a
deep trust in the dentist and the staff.
The differences in these studies can depend on several factors,
besides the possible difference in information and mutual discussion
pattern. The trust in the dentist could also be the result of a long
treatment period and long treatment sessions, which most often is
the case in implant treatment. This has in other studies been shown
to have an impact of the patients relation to the dentist and to
the experience of the treatment result.93,94 The possibility to freely
discuss the treatment options, and to be given the opportunity of
talking about psycho-social factors, has previously been put forward
as important for the subjective opinion of the prosthetic treatment.95
The patient panorama could also be somewhat different in our study
with implant treatment patients compared to the other study with
patients with a periodontal disease. The treatment outcome could
also in many implant treatment cases be more easily described, with
a higher degree of prognostic accuracy, than for periodontal disease.

49
The oral-facial aesthetics seems to be definitely more important
than good dental function for some of the informants, which also
has been described in other studies.96 Patients expressed that their
self-esteem and self-confidence were severely depressed by having
tooth gaps, even when they were only visible for themselves. This is
in accordance with another study, where the eventuality of losing a
tooth or getting dentures was compared to being unemployed.40 The
informants in our study described the feeling of being restored and
regaining self-esteem when they once again got fixed teeth.

gatekeepers expressed by the informants


The informants in the interview study, who were already treated,
were asked if there were any obstacles, gatekeepers, in the decision
making process. The two factors mentioned were cost and dental
anxiety, but neither was described as important. Two of the
informants had hesitated to choose implant treatment because of
the cost, but had all the time been determined to carry through with
the treatment later.
However, a new regulation was introduced in the National
Dental Insurance System in Sweden a few years ago. The regulation
permitted highly subsidised treatment costs for prosthodontic
services. The cost for dental implant therapy is therefore low in an
international perspective. It is likely that this might have an impact
on the desire of implant treatment although most of the informants
declared that they would desire this treatment regardless of cost and
were prepared to take a bank loan, if necessary. The participants in
this study were referred to a specialist clinic with the pronounced
intention of having dental implant treatment. They were to some
degree prepared for the cost and the different parts of the treatment.
Those without the economical resources had probably declined the
offer of referral. As pointed out in another questionnaire study,
treated patients seem to consider the cost worthwhile.91 Maybe only
patients with good economic resources carry through the implant
treatment, or treated patients may consider their quality of life being
so much enhanced that they consider the money well spent.
The opinion that the total cost was not as high as they thought was
unanimous for all the informants in our study. The pre-treatment
cost estimation showed to have good accuracy which strengthened

50
the confidence in the dentist and his/her staff. A weakness of the
study is that these patients had passed the gatekeeping process
and expressed demand. A study of needy patients not demanding
implant treatment would be of great interest but outside the scope
of this study.
Some of the informants described having dental anxiety previously
but had gone through with the treatment without hesitation because
of the pre-treatment information which was considered very
accurate.
Cost and dental anxiety have earlier been discussed as important
gatekeepers. Perhaps this is the case for many dental treatments
options, but not so for this study group. When asked if they knew of
any friends or acquaintances that had declined from implant treatment
because of cost or dental anxiety, there were few such cases. Still,
the gatekeeping may occur long before contact is taken with dental
care, which of course is not perceived in the care system, even less
so in a specialist clinic. A recent two centre qualitative study among
elderly persons two main themes emerged as gatekeepers; patients
fear and anxiety (relating to the pain of surgery, complications of
the procedure and immediate post-surgical denture use), and the
appropriateness of the procedure in an elderly person.84 The impact
of cost was not included in this study. Compared to our study, this
could partly depend on age and cultural differences (appropriateness
for an elderly person). Our study group was younger and perhaps
implant treatment is more commonly accepted treatment option in
Sweden, regardless of age. Another reason for difference could be that
the informants in our study were treated patients and had concluded
their decision making process, and the reported confidence in their
dentist made dental anxiety a minor concern.
Another study has claimed that implant supported fixed dentures
makes the patient regain health and function to a higher degree than
with fixed partial dentures or removable dentures.97 The results in
our study confirms this.
This is also in line with yet another qualitative study regarding
eating, indicating that implant supported mandibular overdentures
gave a significant improvement compared to informants with
adjusted prostheses.98 The informants in our study unanimously
declared the feeling that implant supported fixed partial dentures felt

51
better than a conventional fixed partial denture and was comparable
to their own natural teeth.
Everyone in the study group who had used a removable denture
(all but one), reported a decrease of the ability to sense food tastes
because of the dentures. This effect of the removable denture was
considered as a clear decrease in quality of life. After receiving the
implant supported fixed denture, the ability of sensing food tastes
was regained.
The percentage of elderly individuals without teeth and wearing
removable dentures has dramatically decreased in Sweden during
the last decades.99 On the other hand, there is today a larger share of
the population getting older, and they will probably face the risk of
losing their teeth at a higher age. This is also proposed to be the case
in other parts of the industrialized world, e.g. in the United States.100
This means that in a foreseeable future, there may be many patients
with dentures desiring implant supported dentures.
In line with the results from the present and other studies, it should
be politically urgent to make it possible for those of the denture
wearers who cannot accept their denture, to have the opportunity
to get subsidized dental implant treatment within the national
insurance system.

52
CONCLUSION

The core category and main finding were the importance of the
patients trust and confidence in the dentist and his/her staff in
the process of transforming desire for dental implant treatment
into a manifest demand, and also in making it more likely for the
patients to become satisfied with the treatment result regardless
of complications. Mutual discussions in the treatment planning
process, primarily good pre-treatment information, and accurate
cost estimation were reasons for developing this trust and confidence.
Need, from a conceptual analysis, is constituted in the society,
and in the interaction between patient and dentist. Need does not
always lead to demand for treatment, nor to utilization, depending
on the gatekeeping processes between need and demand, and
between demand and utilization. These processes are influenced
by numerous factors such as education, occupation, income,
individual preferences, costs, cultural differences, psychosocial
factors, comfort, age and accessibility of services. Patients with a
higher level of education, and higher income have a lower gate-
keeping barrier than less wealthy individuals and those with a
lower level of education.
If expensive prosthodontic treatments are made financially
available for all individuals by means of subsidies, this could
influence and change the existing need and create a new need among
the population. In the prosthodontic treatment decision-making
process, the emancipatory perspective with the patient-dentist
dialogue is of utmost importance to achieve an optimal treatment
result. The professional attitude toward need must be that there
is no true objective nor subjective need. Oral health is estimated

53
through dialogue and professional assessment. Need is established
in communication with mutual respect between the profession and
the patient.
Demand must be accepted through the knowledge that there is no
objective need and that demand depends on the patients opinion.
In accordance with this, changes in demand and utilization must be
accepted and considered when prosthodontic treatment options are
discussed and evaluated. Prosthodontic treatment is highly individual
and not immediately related to oral health status, making need and
demand difficult to measure in that respect. Therefore, socio-dental
factors should be included and evaluated in studies on need and
demand and utilization regarding prosthodontic treatment.
This thesis shows that almost all in the study panel expressed
desire for implant treatment in 1999, which is a major increase
in interest compared with the findings in the 1989 questionnaire.
Individuals with a possible treatment need showed a great change in
desire for implant treatment pointing out that when an individuals
need turns from latent to manifest, the treatment desire changes even
more. Manifest need and desire for implant treatment most likely
changes over time. Factors influencing desire for implant treatment
are income and dental status. Age, place of residence, and concern
for dental appearance did no longer influence desire for implant
treatment at the end of the studied 10-year period. Individuals with
removable dentures, or those being edentulous in one or both jaws
had a lower probability to desire implant treatment than those with
all teeth remaining, or with missing teeth replaced by fixed partial
dentures.
Cost is the major gatekeeper for not expressing desire for implant
treatment. Costs, and uncertainty about risks and physical and
technical prerequisites, are among the factors that apparently could
influence the patients choice of prosthodontic treatment.
The interview study confirmed much of the stated facts from the
other studies but also revealed new facts not possible to achieve
from the questionnaires.
Experienced complications like disintegrated implants was not
considered as a result of bad management from the dentist. Instead
the participants put the blame on themselves.

54
All of the informants had considered implant treatment for some
time and made their decision when they felt confident in the dentist
and after discussions with their family and with the dentist.
None of two identified gatekeeping factors, cost and dental anxiety
were important for the decision of getting implant treatment. No
other gatekeeping factors were put forward by the informants in the
qualitative interview study.
A great improvement/recovery in oral health related quality of
life was stated in terms of regaining the feeling of self-esteem and
being secure in social relations. The ability of sensing different food
tastes was also regained after implant treatment and the perception
of the implant supported fixed denture was the same as of own
natural teeth.

55
ACkNOWLEDGEMENT

I wish to express my sincere gratitude to all those, that in different


ways, have helped me in these studies throughout the years. In
particular I wish to express my thanks to:

Professor Bjrn Sderfeldt thank you for always being a most


helpful and supportive primary supervisor, co-author, and advisor.
Your support has been total and there are no words for the
significance of your guidance.
Professor Sigvard Palmqvist thank you for giving me the opportunity
of becoming a prosthodontist and also your sincere support in my
research, and for generously given me advice that has helped me
very much in my work.
Associate professor Mats Kronstrm thank you for giving me
the chance to get into the world of research and science, and your
invaluable way of supporting me in the beginning of the work with
my studies.
My co-auther Ingrid Collin Bagewitz thank you for your consistent
help with my papers, and for your scrupulous reading and valuable
opinions, and for sharing your knowledge of adequate references.
My co-author Ulrika Hallberg-Asklund thank you for helping me
into the world of qualitative research and your generous way of
supporting me in my article. You have made me realise how exciting
qualitative research is.

56
Folktandvrden Uppsala ln with Director Eva Ljung, Associate
professor Pia Gabre and Professor Lars Gahnberg thank you for
the support through the years and for giving me the possibility to
carry through this project with funding and your personal support.
Folktandvrden rebro thank you for supporting the questionnaires
conducted by Professor Sigvard Palmqvist.
Professor Karl Ekstrand thank you for letting me spend time in the
beginning of my research and for always being anxious of pointing
out the importance of conducting research.
My colleges, co-workers and friends at Kaniken and especially
Carina Forsberg thank you. This would not have been possible
without you.
My friend and colleague Alf Eliasson thank you for always helping
me out, whenever I have been puzzled with patients or in my research.
Professor Krister Nilner thank you for your important opinions on
my papers and how to conduct research.
Professor Ann Wennerberg thank you for giving me the opportunity
to fulfil this thesis.
Mr Alborz Soltani thank you for all your kind help and support.
Dr. Maj-Britt Folkunger Sllvik thank you for giving me a role
model helping me in many parts of my daily work.
My family: sa, Petter, Cecilia, Ylva. Thank you for being there. All
my love.

57
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78. Berg E. Acceptance of full dentures. Int Dent J 1993;43:299-306.
79. Walton JN, MacEntee MI. Choosing or refusing oral implants: A pro-
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65
66
Prosthodontics and the Patient: What Is Oral Rehabilitation
Need? Conceptual Analysis of Need and Demand for
Prosthodontic Treatment. Part 1: A Conceptual Analysis
Birger Narby, DDSa/Mats Kronstrm, DDS, PhD/Odont Drb/Bjrn Sderfeldt, PhD, DrMedScc/
Sigvard Palmqvist, DDS, PhD/Odont Drd

Purpose: The concepts of need and demand are central in studies on dental care. In
the literature, a normative definition is often used, but it pays little attention to the
individuals personal comfort and quality of life. Need and demand for prosthodontic
services are difficult to measure, as prosthodontic treatment is highly individual and
not closely related to edentulousness. Need, however defined, does not always lead
to demand for treatment, depending on a variety of factors. Materials and Methods:
The present article is part of a larger study in which the intention is to evaluate need
and demand for prosthodontic treatment among the participants in a 1989 and 1999
longitudinal study of a population sample. As the first step, this article reports a
conceptual analysis of the need concept from the literature. Results: Need is stated
as socially established in the interaction between patient and clinician. It makes
demand dependent on available treatment options from the care provider and society.
In the prosthetic treatment decision-making process, the emancipatory perspective
with the patient-clinician dialogue is of utmost importance to achieve an optimal
treatment result. Conclusion: The professional attitude toward need must be that
there is no true objective or subjective need. Need is established only in a
communicative dialogue with mutual respect between the professional and the
patient. Int J Prosthodont 2005;18:7579.

T he concepts of need and demand are central in


studies on dentistry. Need has been defined as
the quantity of dental health care which expert opin-
Furthermore, it requires knowledge about the individ-
uals dental health situation, available treatment op-
tions, and exact definitions of what should be regarded
ion judges ought to be consumed over a relevant time as dentally healthy.2,3 The decisive argument against
period, in order to remain or become as dentally such a definition is that it gives the power to decide
healthy as is permitted by existing knowledge. 1 need to someone other than the person who has the
However, such a definition gives little attention to the need. Thus, it contradicts the whole idea of patient
individuals personal comfort and quality of life. empowerment,4 which is the central tenet of modern
health theory.
aConsultant, Department of Prosthetic Dentistry, Public Dental Health Need, however defined, does not always lead to de-
Service, Uppsala, Sweden. mand for treatment,4 depending on factors such as in-
bAssociate Professor, Department of Prosthetic Dentistry, Malm dividual preferences, cost, cultural differences, psy-
University, Sweden; and Department of Dental Clinical Sciences, chosocial considerations, comfort, age, and accessibility
Faculty of Dentistry, Dalhousie University, Halifax, Canada.
cProfessor and Chair, Department of Oral Public Health, Malm
of services. Need and demand for prosthodontic ser-
University, Sweden. vices are difficult to measure, as prosthodontic treat-
dProfessor Emeritus, Department of Prosthetic Dentistry, Malm ment is highly individual and not directly related to, eg,
University, Sweden. edentulousness5,6 or masticatory function.6,7 In most in-
Correspondence to: Dr Birger Narby, Department of Prosthetic dustrialized countries, the demand for prosthodontic
Dentistry, Folktandvrden, Box 602, Uppsala S-751 25, Sweden. treatment is more influenced by esthetic demands
Fax: + 46 18 692947. e-mail: birger.narby@lul.se rather than a few missing teeth in the posterior re-

Volume 18, Number 1, 2005 75


Defining Oral Rehabilitation Need: Part 1

gions.7,8 Therefore, so-called sociodental factors, so- Does Human Need Exist?
cial and cultural background, socioeconomic aspects,
oral comfort, and appearance should be included and The concept of need belongs to the social sciences,
evaluated in studies on need and demand for prostho- where many suggestions differ from the relatively unan-
dontic treatment. imous medical traditions. There is still no generally ac-
Longitudinal studies are necessary when studying cepted method for measuring human welfare because
need and demand for prosthodontic treatment. There of the difficulties of defining human needs. Moreover,
are, however, few such reports in the literature.9 The human needs have been considered to be relative rather
present article is part of a larger study in which the in- than a generally applicable concept.18 If need is defined
tention is to evaluate need and demand for prostho- by professionals, this simply pits one subjective opinion
dontic treatment among the participants in a 1989 and the professionalsagainst another subjective opinion
1999 longitudinal study of a population sample. This the patients. In a conflict situation, the strongest party
analysis (see Appendix) will set the theoretical ground prevails, usually the professional. A subjectivist and rel-
for the analysis of data from the longitudinal study ativist conception of need therefore inevitably gives a
mentioned above. disadvantage to those who are too weak, old, or sick to
In 1965, David Easton10,11 presented a model in express their own needs, precisely those persons whose
which need is transformed through a gatekeeping needs the professional should try to meet.
process that filters and aggregates the need into de-
mand. The present study performed a conceptual Objective Need
analysis of the need concept from the literature; a
forthcoming survey will focus on the gatekeeping There are theories suggesting that objective needs do
processes between need and demand and between exist, and that the most important attributes are phys-
demand and utilization of dental treatment.1012 ical health and autonomy.18 Autonomy is impaired
when there is a deficit of three attributes: mental health,
Widening Definitions of Health and Need cognitive skills, and opportunities to engage in social
participation.
Needs have been described as states of a client that There are other, simpler attempts to define objec-
create a requirement for care,13 which gives a poten- tive needs, and one theory suggests a hierarchy of
tial for service but does not always lead to service, and needs in which the most basic needs must be met be-
use of services does not always come from need. This fore needs higher in the hierarchy can be actualized.19
transformation of need into use of service is complex. This implies that health needs must thus be satisfied
There is, furthermore, the possibility that providers of before autonomy, as the need for health is a condition
health care, as dentists, also bring their own needs, for subsistence.
wants, and demands to the clinical situation, and that
this may have an important impact on the utilization Taxonomy of Need
of care.14 The most self-evident need felt by a physi-
cian in relation to patients is the need to make sick A taxonomy of need was presented in 1972 by
people well or, for a dentist, to rehabilitate people Bradshaw,20 who divides need into four separate de-
with poor dentition or occlusal disturbance. A common finitions:
image of a rational clinician is that of someone who
always performs sophisticated treatments.15 To sep- Normative need is that which the expert or profes-
arate the clinicians own needs, wants, and demands sional defines as need in any given situation. A
from the clinical decision-making process will, to desirable standard is decided and compared to
some extent, give clues to which treatment is provided. actual circumstances; if an individual or group falls
It has also been suggested that economic incentives short of the desirable standard, they are identified
exist for the care provider to exaggerate or minimize as being in need. This is reminiscent of the objec-
needs in the patient.16 tivist idea of need.
A definition including effectiveness of treatment, Felt need is equated with want expressed after self-
often used in evidence-based medicine,1 suggests that, assessment by the individual or population; it is thus
A need for medical care exists when an individual has a subjectivist idea of need. A study of prosthodon-
an illness or disability for which there is an effective and tic treatment need showed that subjective need
acceptable treatment or cure.17 Still, the concept of without a normative need is rare.21 In only one third
need can be analyzed further. of the studied treatments did normative and sub-
jective need coincide; normative need was signifi-
cantly higher. The discrepancy between normative

76 The International Journal of Prosthodontics


Narby et al

and subjective need is in accordance with other re- Emancipatory Need


ports.2225
Expressed need is equivalent to demand, ie, felt Need and demand are constituted in a dialogue be-
need turned into action.20 tween the patient and professional in which the pro-
Comparative need is assessed by studying the char- fessional should discern latent needs that are relevant
acteristics of a population using a service; if there but may be subconscious or unexpressed.33 One can
are people with similar characteristics not receiv- distinguish between manifest and latent needs. A treat-
ing service, they are in need. This definition has ment need becomes manifest when new treatment al-
been used to assess needs of both individuals and ternatives emerge, as with, for instance, dental implant
areas. In the empirical parts of the present study, treatment. Perceived need is dependent on the credi-
such a need conception was used. ble opportunities to meet the need. A professional way
of dealing with latent and manifest need is through di-
Sheiham and Spencer26 have analyzed normative alogue, which is the emancipatory perspective.
need as being a commonly used type of need assess- Especially in prosthodontics, there are legitimate
ment in dental health planning. However, by using claims for dialogue, and an ordinary decision-making
normative need, diseases are identified without con- process should also involve the patient. Prosthodontics
sidering the subjective perception of the patient and the is not a specialty dealing with treatment of an oral dis-
relevance to the disease-oriented or biomedical ap- ease, but rather the branch of dentistry that focuses on
proach.26 Sheiham and Spencer26 find four major short- oral reconstruction from a functional and esthetic point
comings of normative need. of view.34
First, professional judgments are neither free of in- Evidence-based dentistry is considered the foun-
dividual valuation nor objective. There is intra- and in- dation of modern health care, but it is not the only
terexaminer variability in judgment and decision mak- method to be considered in prosthodontic treatments.
ing.27 Variables such as age, practice beliefs, and price Any evidence-based therapy must be used with care,
competition in the marketplace have effects on treat- as the treatment plan must be based not only on avail-
ment.28 For example, many young clinicians in Sweden able treatment options, but also on the individuals
today have little or no experience in complete denture need. Therefore, evidence-based therapy cannot be
treatment, unlike general practitioners a few decades conclusive. Studies show considerable differences in
ago, which could lead to avoidance of proposing such how clinicians approach treatment alternatives and
treatment options because of lack of experience.29 decide what the best option is.27,28 It has also been
Second, the normative need defined by clinicians shown that patient satisfaction and need fulfillment in-
does not necessarily correspond to the experienced crease if the patient is personally involved in the treat-
need of the patient. Patient satisfaction is not always ment planning process.35
related to the clinical assessment,30 and, for example, In some situations where patients have dental needs
lack of posterior teeth leads to demand for prostho- the professional cannot diagnose or satisfy, the need
dontic treatment in only some situations. Both type could be projections of discontent with situations or
and quality of the treatment are important, but not de- general conditions of life.36 Thus, dysmorphophobia is
cisive for patient satisfaction,31 although there is a re- an example in which dialogue is central in dealing
lationship between health-related quality of life mea- with the problem of jointly trying to decide actual den-
sures and clinical oral indicators.32 tal need.
Third, there is not always correspondence between
political and professional need assessment. An exam- Conclusion
ple can be found in the Swedish National Dental Health
Insurance System, in which persons aged 65 years Oral health is estimated through dialogue and profes-
and over receive a highly subsidized part of the total sional assessment. Need is constituted by society and
cost for prosthodontic treatment, irrespective of their the interaction between patient and clinician. It makes
dental health or paying ability. This was a purely polit- demand dependent on available treatment options and
ical decision without professional support. resources from the care provider and society. If ex-
Fourth, there are not always resources to meet a nor- pensive prosthodontic treatments are made financially
mative need. All dental needs cannot be met. The need available for all individuals by means of subsidies, this
definitions depend on realistic treatment possibilities. could influence the existing need and create a new
Economic subsidies make new treatments, eg, dental need among the population. In the prosthodontic treat-
implants, available. Need perceptions and demand ment decision-making process, the emancipatory per-
grow rapidly, which points to another conception of spective with patient-clinician dialogue is of utmost im-
need, so-called emancipatory need. portance to achieve an optimal treatment result. The

Volume 18, Number 1, 2005 77


Defining Oral Rehabilitation Need: Part 1

professional attitude toward need must be that there 5. Basker R, OMullane DM. Removable prosthodontic services re-
is no true objective or subjective need. Need is estab- lated to need and demand. In: wall B, Kyser AF, Carlsson GE
lished only in communication, with mutual respect be- (eds). Prosthodontics. Principles and Management Strategies.
London: Mosby-Wolfe, 1996:223235.
tween the professional and patient. 6. Todd JE, Lader D. Adult Dental Health 1988. London: Her Majestys
Stationery Office, 1991.
Appendix 7. Kyser AF, Witter DJ. Oral function needs and its consequences for
dentulous older people. Community Dent Health 1985;2:285291.
8. Oosterhaven SP, Westert GP, Schaub RMH. Perception and sig-
Search Strategy
nificance of dental appearance, the case of missing teeth.
Community Dent Oral Epidemiol 1989;17:123126.
A literature survey was done by applying the PubMed 9. Eklund SA, Burt BA. Risk factors for total tooth loss in the United
database. PubMed provides access to bibliographic in- States, longitudinal analysis of national data. J Public Health Data
formation that includes MEDLINE, covering the fields 1994;54:514.
10. Easton D. A Framework for Political Analysis. Englewood Cliffs, NJ:
of dentistry, medicine, nursing, veterinary medicine, the
Prentice-Hall, 1965.
health care system, and the preclinical sciences. 11. Easton D. A System Analysis of Political Life. New York: Wiley, 1965.
The search was continued in MEDLINE and 12. Stone DA. Physicians as gatekeepers: Illness certification as a ra-
PsycINFO. The survey covered the period from 1994 to tioning device. Public Policy 1979;27:227254.
August 2002 and used the Medical Subject Heading 13. Donabedian A. Aspects of Medical Care Administration: Specifying
(MeSH) terms: Requirements for Health Care. Cambridge, MA: Harvard University
Press, 1973.
14. Avorn J. Needs, wants, demands, and interests. In: Bayer R,
need OR demand OR attitude OR requirement; Caplan AC, Davids N (eds). In Search of Equity. New York: Plenum,
prosthodontics OR dental implants OR dentistry 1983.
OR dentists; 15. Sderfeldt B. A system theoretical perspective on the health care
system [in Swedish]. Socialmedicin Tidskr 1981;4-5:239245.
combination (1) AND (2)
16. Grytten J. The effect of the price of dental services on their demand
limits: English, human and utilisation in Norway. Community Dent Health 1991;8:303310.
17. Matthew GK. Measuring need and evaluating services. In:
The search strategy resulted in 509 articles, of which McLachlan G (ed). Portfolio for Health. Oxford, UK: Oxford University
147 abstracts were collected from articles with an ap- Press, 1971.
18. Gough I. Economic institutions and the satisfaction of human
proach to dentistry or concentration on conceptual
needs. J Econ Iss 1994;28:2566.
analysis of the MeSH terms in the first selection group. 19. Maslow A. Motivation and Personality, ed 2. New York: Harper and
Furthermore, a hand search of the references in these Row, 1954.
papers was undertaken to find more articles of special 20. Bradshaw JS. A taxonomy of social need. In: McLachlan G (ed).
interest. Problems and Progress in Medical Care. Seventh Series. Oxford,
UK: Oxford University Press, 1972:6982.
21. Walter MH, Wolf BH, Rieger C, Boening KW. Prosthetic treatment
Selection Criteria need in a representative German sample. J Oral Rehabil 2001;28:
708716.
Papers were excluded if the studies they reported did 22. Davis P. Converting the need for care into demand for services.
not have an approach to the patients needs, demands, Int Dent J 1982;32:271280.
23. Elias AC, Sheiham A. The relationship between satisfaction with
and attitudes.
mouth and number, position and conditions of teeth: Studies in
Brazilian adults. J Oral Rehabil 1999;26:5371.
Acknowledgment 24. Kiyak HA. Reducing barriers to older persons use of dental ser-
vices. Int Dent J 1989;39:95102.
This study was supported by The Public Dental Health Service, 25. Ettinger RL. Clinical decision making in the dental treatment of
Uppsala County Council, Sweden. the elderly. Gerodontology 1984;3:157165.
26. Sheiham A, Spencer J. Health need assessment. In: Pine CM
(ed). Community Oral Health. London: Wright, 1997:3954.
References 27. Kronstrm M, Palmqvist S, Sderfeldt B, Carlsson GE. General
dentists attitudes toward delegation, information, and patient in-
1. Spencer AJ. The estimation of need for dental care. J Public fluence in a prosthodontic context. Int J Prosthodont 1999;12:4550.
Health Dent 1980;40:311327. 28. Grembowski D, Milgrom P, Fiset L. Factors influencing variation
2. Jeffers JR, Bognanno MF, Bartlett JC. On the demand versus in dentist service rates. J Public Health Dent 1990;50:235243.
need for medical services and the concept of shortage. Am J 29. Eriksson T, Kronstrm M, Palmqvist S, Sderfeldt B. Some factors
Public Health 1971;61:4663. influencing the quantity of prosthodontic treatment performed by
3. Beazoglou T, Brown LJ, Heffley D. Dental care utilization over time. general practitioners in public dental service. Swed Dent J 1992;16:
Soc Sci Med 1993;37:14611472. 247-251.
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31. Hakestam U, Karlsson T, Sderfeldt B, Rydn O, Glantz P-O. Does 34. The Academy of Prosthodontics. The glossary of prosthodontic
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Literature Abstract

Group function or canine protection

The study tested the effect of group function and canine protection on general chewing pat-
terns, as well as movement in the terminal part of the chewing cycle. Five subjects were re-
stored with implant-supported fixed complete dentures for the maxilla, and natural dentition or
fixed restorations for the mandible. LEDs (Selspot system) were used to register the chewing
patterns. The light signals were recorded by camera and analyzed in a computer. Canine pro-
tection occlusal scheme was given to the subject. The first registration was performed after 4
months. Then the occlusion was modified to group function, and a second registration was
made five months later. Only two test subjects were able to attend the third occlusal registra-
tion when the occlusal scheme was changed back to canine protection and registration was
made 6 months later. There were several findings between the two occlusal schemes: 1. The
angle of departure was steeper than the angle of approach for the canine protection occlusion,
but there was no statistical difference between these angles in the group function occlusion; 2.
The mean maximal lateral shift and mean total mandibular movement at opening and closing
during chewing of test bread were all greater with group function occlusion than with canine
protection; 3. The mean maximal mandibular velocity was greater with group function occlu-
sion then with canine protection; 4. The variations in three dimensions at the most cranial posi-
tion were mostly greater with group function than with canine protection; and 5. The duration of
the chewing cycle was stable intraindividually between two registrations.

Jemt T, Lundquist S, Hedegard B. J Prosthet Dent 2004;91:5:403408. Reprints: Dr Torsten Jemt,


University of Gteborg Faculty of Odontology Box 33070 Gothenburg 400 33 SwedenJasmine Chun,
Taiwan, Republic of China
Literature Abstract

Risk indicators for posterior tooth fracture

This case-control study of risk indicators for posterior tooth fracture evaluated 39 potential risk
indicators. A total of 200 patients, each with one fractured tooth, and 252 patients (749 control
teeth) without fractures were recruited from a large dental group practice in Portland, Oregon.
Clinical examinations and patient surveys were carried out to obtain information on the list of
potential risk indicators. Clinical examinations were carried out prior to any treatment to collect
information on the fractured tooth and comparison tooth, eg, mobility, Class V restorations,
cervical defects, craze lines, tactilely detectable fracture lines, subsurface discoloration, en-
dodontic access preparations, restorative material, restored surfaces, tooth-supported partial
denture, and canine or group guidance. Relative volume proportion between restorations in the
tooth concerned was also calculated. Patients completed a 14-item questionnaire to allow the
study to elicit demographic data, information about behaviors, experiences, and symptoms that
may be associated with tooth fracture. For control subjects, a minimum of two restored teeth of
the selected tooth type that were uncrowned was used. Logistic regression (backward-selec-
tion method) was used to develop models identifying risk indicators associated with fractures
between case and control subjects, as well as between case and comparison teeth in case
subjects. Two risk indicators were strongly associated with cusp fracture in both models (P <
.001): presence of a tactilely detectable fracture line and the proportional volume of the
restoration.

Bader JD, Shugars DA, Martin JA. J Am Dent Assoc 2004;135:883892. Reference: 21. Reprints: Dr
James D. Bader, Department of Operative Dentistry, School of Dentistry, CB#7450, University of North
Carolina, Chapel Hill, NC 27599-7450. e-mail: jim_bader@unc.eduAlvin G. Wee, Columbus, OH

Volume 18, Number 1, 2005 79


Narby.qxd 2/28/07 9:55 AM Page 183

Prosthodontics and the Patient. Part 2: Need Becoming


Demand, Demand Becoming Utilization
Birger Narby, LDSa/Mats Kronstrm, LDS, PhD/Odont Drb/Bjrn Sderfeldt, PhD, Dr Med Scc/
Sigvard Palmqvist, LDS, PhD/Odont Drd

Purpose: Patients oral health needs are estimated through dialogue and professional
assessment. The concepts of need and demand are vital to studies of dental care and
oral health. Need does not always lead to demand for treatment or to utilization,
depending on the gatekeeping processes between need and demand and between
demand and utilization. Demand must be accepted with the understanding that there
is no objective need and that demand depends on the patients opinion. In
accordance with this, the need for prosthodontic treatment is highly individual and is
not automatically related to oral health status, making need and demand difficult to
measure in that respect. Therefore, sociodental factors should be included and
evaluated in studies of need and demand for utilization of prosthodontic care.
Materials and Methods: This theoretical and analytic paper focuses on the
gatekeeping processes between need and demand and between demand and
utilization of prosthodontic care. Results: The concept of gatekeeping refers to the
social and psychologic processes that transform need into demand and demand into
utilization. It implies that they are complex processes that can render great differences
between demand and actual utilization. Conclusion: It is not possible to estimate a
patients needs for prosthodontic care, since there is no objective need. Demand and
utilization are factors that play an important role in the gatekeeping process. These
factors are dependent on the patients opinion, which is influenced by numerous
factors. Int J Prosthodont 2007;20:183189.

T o correctly assess a patients oral health, both a clin-


ical examination and a dental history obtained
through dialogue are necessary. Traditionally, poor
cess to treatment options, technologic possibilities,
social norms, and attitudes among both care providers
and patients. In the prosthodontic decision-making
oral health has been regarded as a component of process, the emancipatory perspective with the pa-
treatment need, but such need is also socially con- tient-clinician dialogue at the forefront plays a central
structed and established in the interaction between pa- role in achieving optimal treatment results.2
tient and clinician.1 Perceived need may depend on ac- A conceptual analysis of need has previously been
reported.1 It is also important to examine how need may
transfer into demand and the mechanisms involved in
such a process. It is also of special interest to investi-
gate how these factors can be identified, especially
aSenior Consultant, Department of Prosthetic Dentistry, Public Dental from a prosthodontic point of view. Studies have shown
Health Service, Uppsala, Sweden. that several gatekeeping processes are involved
bAssociate Professor, Department of Dental Clinical Sciences,
when need is transformed into demand. The concept
Faculty of Dentistry, Dalhousie University, Halifax, Canada.
cProfessor and Chair, Department of Oral Public Health, Malm
of gatekeeping has been identified as the social and
University, Malm, Sweden.
psychologic processes that transform need into de-
dProfessor Emeritus, Department of Prosthetic Dentistry, Malm mand and demand into utilization.35 The present paper
University, Sweden. will analyze the gatekeeping process between need
Correspondence to: Dr Birger Narby, Department of Prosthetic
and demand, as well as on the gatekeeping process
Dentistry, Public Dental Health Service, Box 602, S-751 25 Uppsala, between demand and utilization of dental treatment
Sweden. Fax: +46-18-692947. E-mail: birger.narby@lul.se from a theoretical point of view (Fig 1).

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Prosthodontics and the Patient. Part 2

Need
Gatekeeping 1 References
Gatekeeping 1
Problems in oral health,
724
quality of life
Demand Need Demand
Psychologic factors,
2534
Gatekeeping 2 health beliefs

Social structure factors,


Utilization 9,3543
demographics

Fig 1 Transformation of need into care utilization. Fig 2 The gatekeeping structure between need and demand.

Prosthodontic treatments are often associated with


Gatekeeping 2 References
a high cost for the patient. Supplier-induced demand
and dental insurance schemes are factors of interest
Explanatory model for 11,4451 in that respect. The aim of the present paper is to an-
utilization alyze the gatekeeping mechanisms with respect to
Demand Utilization the patient, to different treatment options, and to ser-
Oral health and service 47, 5261
vice utilization.
utilization
11,19,44,47,
Economic factors 51,6271 Gatekeeping 1: Between Need and Demand
Dental insurace 51,60,68,72,
Oral Health: Complete and Partial Edentulism
73

Edentulous patients with denture problems do not


Fig 3 The gatekeeping structure between demand and uti-
lization.
necessarily translate such concern into demand for
treatment.7 Most edentulous individuals adapt to wear-
ing complete dentures; however, for some, impaired
oral health resulting in loss of the natural dentition is
Gatekeeping a serious life event and has been compared with other
stressful events such as divorce or retirement.8 It can
The process between need and demand is influenced by be experienced as a mutilation or a serious change of
several factors, identified as barriers or gatekeepers6 (Fig life.9 A greater concern about demand is a conse-
2). Need can be regarded as latent or manifest. quence of the realization that there is no objective
Becoming aware of a latent need, which eventually be- need. Still, in most cases demand must be recognized
comes manifest, is a multifactorial process that involves: as the result of an actual need. There are, of course,
financial aspects involved in the process related to
Oral health and edentulism need and demand for prosthodontic treatment, and it
Quality of life and perception of need is well known that edentulism is more prevalent among
Psychologic factors (eg, dental anxiety state) individuals with low or no income.
Health beliefs (attitudes, values, and behavior) Need and demand for prosthodontic treatment
Social structure (education, occupation, and ethnicity) among partially edentulous individuals are even more
Demographics (age, gender, marital status, and income) difficult to estimate. A missing maxillary anterior tooth
is a strong incentive for demanding treatment, while
The process between demand and utilization of loss of a posterior tooth usually is not. Position and
dental services (Fig 3) is closely related to social and number of teeth have strong effects on the perceived
economic factors, which can act as inhibitors in the need for prosthodontic treatment.10,11
process between a demand and utilization of this de- The results of the replacement of lost teeth with re-
mand. Gatekeeping mechanisms have been used to movable dentures are contradictory, indicating that de-
the control costs of care and to promote cooperation mand is dependent on the patients opinion.12 It has been
between different groups of care providers.6 shown that about 25% to 50% of individuals who have

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removable dentures seldom or never use them.13 Cost found to be a major reason for transforming need into
seems to play an important role here, and there is a higher demand.32 New adhesive techniques with veneers and
probability of low dental care utilization among those all-ceramic restorations require minimal tooth prepara-
who consider dental care as expensive compared to those tion. The increasing commercialization of body image
who state that they have no problem with the cost.11 and changes in social normative standards have resulted
The shortened dental arch (SDA) concept, first in- in subjective demand for cosmetic dental care, so that
troduced by Kyser14 and Witter et al,15 is becoming practitioners may have difficulty identifying patient need.
widely accepted among many dental practitioners, as However, the demand for cosmetic dental care varies in
it seems to reflect the actual perceived demand among different age groups and in different cultures.
most partially edentulous individuals. The principles of Expectations of dental health status and dental care may
the SDA concept include different levels of functional vary between individuals with different social norms
needs in relation to age and other individual factors. It and cultural traditions.33,34 In some ethnic and social
further implies that teeth should be replaced only groups, edentulism following dental disease is consid-
when there is a demand to restore essential functions, ered as a likely development and a natural part of life.
such as esthetics, oral comfort, and occlusal stability.
With this concept, limited treatment goals can be Social Structure and Demographics
achieved and still satisfy patient demands.
There seems to be a gender variation in the social im-
Quality of Life pact of oral health on perceived QOL. Women report-
edly consider oral health as more important, whereas
Oral quality of life (QOL) includes freedom from pain and men rank chewing ability higher.9,3537 But there are
optimal oral function and dental appearance. 16,17 also contradictory reports regarding the need for
Subsequent studies of elderly individuals found signifi- prosthodontic services in men versus women.3840
cant relationships between oral health status and QOL Edentulism may be correlated with age and gender
as well as between self-esteem and perceived oral health and is also more prevalent in rural areas, whereas
status.9,18,19 The introduction of dental implants has rev- there seems to be a greater demand for treatment in
olutionized prosthetic dentistry,20 and reports indicate more densely populated areas.4042 Factors such as
that increased patient satisfaction and perceived QOL are ethnicity, cultural attitudes, and standard of living have
strongly associated with the use of dental implants.2124 an impact on need and attitudes toward dental care,
where, for instance, citizens in urban Western societies
Psychologic Factors have a much higher level of demand for treatment
than patients in less developed countries.43 Individuals
Four main groups of psychosocial factors have been with high levels of education, prominent occupations,
identified as potential barriers between need and de- and high incomes have a lower barrier to treatment de-
mand: (1) dental anxiety, (2) perception of need, (3) mand compared with those with a low level of educa-
financial concerns, and (4) lack of access.25 The 2 lat- tion and reduced financial capacity. It is likely that
ter factors belong mainly to the gatekeeping process global internationalization and growing prosperity may
between demand and utilization. Concern about oral change the need for dental treatment, and through
health has been reported as significantly predicting changes in the gatekeeping process, new demands
perceived treatment need.26 Individuals who regularly may be developed. Moreover, technical achievements
attend a dental office are likely to have a much higher in the field of prosthetic dentistry may also contribute
perceived need than irregular attendees. Barriers such to a change in demand among individuals.
as fear of pain, anxiety, cost, and long waiting times
have been found to have little influence, but the clin- Gatekeeping 2: Between Demand and
icians recommendation was found to be important.27,28 Utilization of Dental Treatment
Dental anxiety is one of the major parts of the psy-
chologic barrier between need and demand. It appears Explanatory Models of Utilization
to be dependent mostly on experiences from youth,29
but some patients might use it as a pretext not to meet Originating from models of health service utilization,
a demand because of a poor economic situation. several explanatory models for utilization of dental care
have been put forward. A sociologic comprehensive
Health Beliefs conflict model from Petersen emphasizes 4 groups of
explanatory factors to explain inequalities in dental
Healthy teeth are important to most people regardless health.44,45
of age.30,31 Dissatisfaction with appearance has been

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Prosthodontics and the Patient. Part 2

1. Background factors comprising experiences in the Socioeconomic factors. Social and economic fac-
public dental service for children. There are associ- tors can influence the process between recognition of
ations between poor dental conditions and poor a demand and utilization of this demand. There is ev-
social conditions.11 It has also been shown that idence that national economic recession, to some ex-
there is a great amount of variation between gen- tent, affects utilization of dental services.62 In countries
eral practitioners regarding prosthodontic services. with public health care systems, accessibility and fi-
About 20% of the variation in prosthodontic service nancial aspects are important factors for utilization.44,47
rate was related to the clinician and not to the pa- Individuals with low income have a lower level of uti-
tient; factors related to the clinician, such as gen- lization and spend less money on dental care11,63 com-
der, age, years in the profession, and prosthodon- pared with individuals with higher income, even in
tic production, seem to have a great impact on the subsidized systems.64
clinicians choice of prosthodontic treatment.46 The Cost and supplier factors. Cost is the most fre-
clinicians medical or ethical consideration of a pa- quently mentioned barrier regarding utilization of den-
tients demand will sometimes affect the gatekeep- tal care, but there is evidence that free or reduced-cost
ing process, resulting in no treatment. services increase utilization only slightly.65 However,
2. Socioeconomic factors comprise work and living dental care utilization could be related to attitudes to-
conditions and social norms and values.47 Low ed- ward costs.11 Refraining from dental care because of
ucation and advancing age have strong correla- the high cost may negatively affect the self-image of
tions with few remaining teeth, and the prevalence individuals who have a perceived need because of
of removable dentures indicates socioeconomic in- poor dental health.19 Dental insurance schemes have
equality in dental conditions.48 Social differences in a positive influence on attitudes and motivations for
dental care utilization are related to treatment costs dental services and therefore could increase utilization
and attitudes toward cost.11 of dental services.51 However, the use of dental ser-
3. Individual factors comprise dental visit habits, atti- vices is also influenced by socioeconomic factors, and
tudes, and opinions regarding teeth and dental care. insurance schemes may play only a limited role in
4. Dental health service system factors include treat- changing this.64,66 Individual factors such as attitudes
ment fees and subsidies, availability and accessi- and opinions regarding teeth and dental care, as well
bility, and behavior of the practitioner.49,50 The in- as dental anxiety, might in many cases have a greater
troduction of a subsidy system normally increases influence on demand and utilization. Treatment fees
utilization.51 In a system with limited dental man- seem to have a greater impact on utilization than on
power capacity, there may be a risk that patients demand.67,68
may not receive adequate care, especially those However, an example of the reverse situation was
who require extensive prosthodontic treatment. seen when a new regulation was introduced in the
National Dental Insurance System in Sweden a few
Oral Health and Service Utilization years ago. The regulation permitted highly subsidized
treatment costs for prosthodontic services and in-
Utilization is conceived as the received amount of cluded only patients age 65 and older. The demand
care; the most common measure is the annual num- and utilization for extensive conventional fixed and
ber of dental visits per person. Usually, there is a pre- implant-supported prosthodontic treatments increased
sumption that a high level of utilization in a population dramatically, and the cost of the new regulation was
has a positive correlation with oral health.47,52,53 Other 3 times higher than estimated. It seems that demand
studies suggest that dental treatments may be per- and utilization in this case were highly dependent on
formed as a result of iatrogenic injuries and are also actual costs.
related to the so-called supplier-induced demand.54 One would have expected that the traditional gate-
Oral health is also likely to affect utilization in a reverse keeping process between need, demand, and utiliza-
relationship, meaning that good oral health is closely tion changes quite dramatically in a situation in which
related to a high level of utilization of dental services.55 patients, through a subsidized system, are given the fi-
Several studies indicate that edentulism per se is re- nancial capacity to choose a treatment and meet a la-
lated to a low level of utilization.5658 Extensive prostho- tent need. The clinicians role in a highly subsidized
dontic treatments will require maintenance. The need dental health care system should also be considered
for maintenance is usually higher for removable pros- because of the risk of supplier-induced demand, ie,
theses than for fixed prostheses, and several studies overconsumption of medical services generated by
indicate excellent long-term survival rates following the economic self-interest of physicians. This has also
treatment with fixed prostheses.5961 been discussed with regard to dental services.69,70
Private practitioners and dental clinicians employed in

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Narby et al

the Public Dental Health Service have different incen- Acknowledgment


tives.70,71 It has been shown that the type of care or-
ganization influences both utilization and cost of care, This study was supported by The Public Dental Health Service,
Uppsala County Council, Sweden.
resulting in higher costs and more frequent utilization
for those attending private care.71
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Literature Abstract

Facial disfigurement in patients with head and neck cancer: The role of social self-efficacy

The purpose of this clinical study was to investigate the role of social self-efficacy in patients with facial disfigurement with respect to
their psychologic and social functioning. Social self-efficacy was defined as the extent to which patients believe that they are capa-
ble of exercising control over the reaction and openness of others. Consecutive patients during routine check-up appointments who
met the eligibility criteria were asked to participate in this study. A total of 76 patients participated (72% response rate), which was a
representative sample in terms of age and gender of the head and neck cancer population seen at this hospital. The average age of
the 44 males and 32 females in the study was 58 years (SD = 12.69). The extent of facial disfigurement (1 = not at all to 4 = very)
was rated for each patient, with a mean score of 1.97 found (SD = 0.97). Impairments of patients facial expressions (1 = not at all to
4 = very much) were rated by physicians, with a mean score of 2.17 found (SD = 1.62). Patients reported social self-efficacy using a
4-point scale (1 = never to 4 = always), with a mean of 3.04 found (SD = 0.41). Psychologic distress was assessed using the State-
Trait Anxiety Inventory, another 4-point scale (1 = not at all to 4 = very much), with a mean of 1.64 found (SD = 0.66). Patients level
of distress in reaction to unpleasant behavior of others was assessed using a 4-point scale (1 = seldom to 4 = very often), with a
mean of 1.58 found (SD = 0.75). Finally, the mean score for patients level of social isolation (1 = never to 4 = always) was found to
be 1.83 (SD = 0.46). Regression analyses revealed an interaction effect between extent of facial disfigurement and social self-effi-
cacy on psychologic distress. Regression analyses also revealed an interaction effect between extent of facial disfigurement and so-
cial self-efficacy on patients distress in reaction to others unpleasant behavior. In conclusion, facial disfigurement, as assessed
both by patients and physicians, was positively related to psychologic distress and distress in reaction to others unpleasant behav-
ior, but only when patients did not feel self-efficacious in social encounters.

Hagedoorn M, Molleman E. Health Psychol 2006;25:643647. References: 29. Reprints: Mariet Hagedoorn, Department of Public Health and
Health Psychology, Northern Center for Health Care Research, University Medical Center Groningen, University of Groningen, The Netherlands, PO
Box 196, Groningen 9700 AD, The Netherlands. E-mail: m.hagedoorn@med.umcg.nlAlvin G. Wee, OSU College of Dentistry, Columbus, OH

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Changes in Attitudes Toward Desire for Implant Treatment:


A Longitudinal Study of a Middle-Aged and Older Swedish
Population
Birger Narby, LDSa/Mats Kronstrm, DDS, PhD/Odont Drb/Bjrn Sderfeldt, PhD, Dr Med Scc/
Sigvard Palmqvist, LDS, PhD/Odont Drd

Purpose: To assess, at a 10-year interval, changes in attitudes toward desire for


implant treatment among middle-aged and older Swedish subjects with respect to
dental status. Materials and Methods: Three thousand subjects, residents of rebro
County, Sweden, were surveyed via the same questionnaire in 1989 and again in
1999 regarding their possible need for and interest in implant-based prosthodontic
treatment. Results: One thousand six hundred sixty-five subjects responded to both
surveys. In 1989 few respondents indicated an interest in implant treatment, whereas
in 1999, 92% of those who had not indicated an interest in the earlier survey now
indicated that they desired implant treatment. The cohort reporting having no teeth
had a considerable lower increase in desire. Among those who reported a possible
treatment need (ie, missing 1 or more teeth and had not had them replaced or those
who wore complete dentures), cost was the most commonly cited reason for declining
implant treatment. Conclusions: There was a dramatic increase in the interest for
implant treatment over the period from 1989 to 1999. Changes in awareness of
implant treatment, along with an expansion in the number of qualified providers, may
have contributed to this increase. Int J Prosthodont 2008;21:481485.

O ral diseases are not cured by means of prostho-


dontic treatment. Instead, the main role of
prosthodontics is the rehabilitation of patients after loss
ing processes between both need and demand and
between demand and utilization.3 Attempts have also
been made to evaluate need and demand for pros-
of teeth and oral function. However, there are no gen- thetic services over time in populations.4 Subjective
erally accepted rules about how to estimate need, need should not be considered as equivalent to de-
demand, or utilization of prosthodontic services in mand for treatment but rather as a prerequisite for a
most situations, since individual preferences play a possible demand. However, the definition of objective
very important role.1,2 need by professionals merely puts one subjective opin-
Many factors are involved in the prosthodontic treat- ionthe professionalsagainst another subjective
ment process. The patients financial situation has a opinionthe patients. In this study, desire for
great impact, and patient preference is also an impor- implants will be referred to as possible demand.
tant factor. Attention has been paid to the gatekeep- Because of new technology, more restorative options
have become available for partially and completely
edentulous patients, and therefore changes in de-
mand for prosthodontic treatment are interesting to
aSenior Consultant, Department of Prosthetic Dentistry, Public Dental evaluate in longitudinal studies. The need for implant
Health Service, Uppsala, Sweden. treatment in particular has come into focus, since this
bAssociate Professor, Department of Restorative Dentistry, School
treatment option has provided excellent long-term
of Dentistry, University of Washington, Seattle, Washington.
cProfessor and Chair, Department of Oral Public Health, Malm results in the rehabilitation of the partially or completely
University, Malm, Sweden. edentulous patient.
dProfessor Emeritus, Malm University, Malm, Sweden. The purpose of the present study was to examine
Correspondence to: Dr Birger Narby, Department of Prosthetic
changes in attitudes toward desire for implant treat-
Dentistry, Public Dental Health Service, Box 602, S-751 25 Uppsala, ment over time with respect to dental status in a pop-
Sweden. Fax: +46 18 692947. E-mail: birger.narby@lul.se ulation of middle-aged and older individuals in Sweden.

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Changes in Attitudes Toward Desire for Implant Treatment

Materials and Methods the maxilla, for a single-tooth implant restoration, and
for complete maxillary and mandibular dentures. The
Two questionnaire studies were performed, one in 1989 cost of implant treatment was considerable, although
and the other in 1999, with the intention of evaluating such treatment was subsidized by the national dental
the desire for implant treatment among 3,000 subjects insurance system. For example, the treatment cost for
aged 45 to 69 years in rebro County, Sweden.5,6 The a complete-arch fixed implant-supported prosthesis
participants were randomly selected from the official was approximately 5 times higher than that for con-
population register. This Swedish county has about ventional removable dentures in both 1989 and 1999.
280,000 inhabitants and was considered average Questions presented elsewhere related to the sub-
socially and economically at the time of the studies.7 jects dental conditions and desire for implant treat-
A questionnaire was mailed to all subjects, and the ment. Participants missing 1 or more teeth that had not
response rate in 1989 was 79.4% (2,383 individuals). been replaced, and those with removable denture(s),
Of the original sample, 2,708 respondents were were considered to have a possible treatment need.
found in the national population register 10 years later, Subjects who reported that all teeth remained were
on the basis of the criteria that they were alive and still asked 2 hypothetical questions about what prostho-
resided in rebro County. In 1999, a new questionnaire dontic treatment they would prefer if they lost 1, a few,
was mailed to them. or all teeth. The response options included no treat-
The number of respondents in the 1999 survey was ment, dental implants, conventional fixed partial
1,848, yielding a response rate of 68%. Among those, denture, and removable denture. No dont know
1,665 (90%) had also responded in the 1989 survey. The response alternative was presented for any of the ques-
individuals who responded in both 1989 and 1999 con- tions. Only those who responded that they would
stituted the panel used in this study and accounted for choose dental implants were considered having a pos-
56% of the 1989 survey sample. sible desire for such treatment. The total panel was
A nonresponse analysis was presented earlier.7 A divided into 2 groupsthose with and those without
comparison of those who responded only in 1989 with changes in dental conditions during this periodto
those participating in both 1989 and 1999 found sig- evaluate their need for implant treatment.
nificant differences between the groups. The subjects
who responded on both occasions were, compared Statistical Methods
with those who responded only in 1989, younger, had
a higher level of education, and reported better dental Statistical significance was determined through
status, ie, fewer of them wore removable dentures. Pearson chi-square test with P < .05 as the significance
Internal nonresponse varied for different questions, level. For dichotomous responses, odds ratios (ORs)
which resulted in different n values for different analy- with 95% confidence intervals were also calculated. All
ses. Among those responding in both 1989 and 1999, calculations were done in SPSS 11.0.
however, no significant differences in dental condition
were noted between nonresponse groups and the Results
other subjects.7
There was a substantial increase in reported desire for
Questionnaires implant treatment. Ninety-two percent of those who did
not express a desire for implants in 1989 had changed
The questionnaire sought to assess dental conditions their mind 10 years later (Table 1). There was a very
and opinions regarding dental implants. The variables high probability (OR = 3.9) that participants who
used in the questionnaire were published earlier and wanted implant treatment in 1989 held the same opin-
gathered information about dental condition (in 7 cat- ion 10 years later.
egories), socioeconomic conditions, attitudes towards Age group differences among those who desired im-
dentures, and desire for various kinds of prosthodontic plant treatment in 1989 are presented in Table 2. The
treatment.5 reported desire for implant treatment decreased with
The 2 questionnaires were identical except for a few age. There were no significant age differences in 1999,
new questions added in 1999 about the number of lost since almost all respondents desired implants.
teeth, prosthodontic treatments, and various compli- Forty-seven of the 111 edentulous individuals (7% of
cations having occurred since the previous survey. the panel) answered the questions regarding the desire
Written information about costs and treatment proce- for implant treatment. Two thirds of those (32 individu-
dures for implants was included in both question- als) reported a desire for implant treatment at the time
naires. The information included estimated costs for a of the second questionnaire study. Of those who were
complete-arch fixed implant-supported prosthesis in edentulous and not interested in having implant treat-

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Narby et al

Table 1 Changes in Desire for Implant Treatment Table 2 Desire for Implant Treatment with Respect to
Among Participating Subjects Age in 1989 (n = 2,383)
1999 Age No desire (%) Desire (%) Total (%) n

1989 No desire (%) Desire (%) Total (%) n 4549 54 46 23 558


5059 66 34 36 869
No desire (%) 8 92 61 801 6069 78 22 40 956
Desire (%) 2 98 39 518
Chi-squared = 99.54; degrees of freedom 2; P < .0001.
Total (%) 6 94 100 1,319
Chi-squared = 18.98; degrees of freedom 1; P < .0001, odds ratio 3.9
(95% confidence interval 2.07.4).

ment in 1989, 38% changed their opinion and reported Table 3 Changes in Desire for Implant Treatment
an affirmative attitude in the study 10 years later. The Among Subjects with Possible Need
increase in desire for implant treatment was similar be- 1999
tween those who reported changes and those without
changes in dental conditions over the 10-year period. 1989 No desire (%) Desire (%) Total (%) n
Changes in desires of respondents with a possible No desire (%) 8 92 77 705
treatment need, missing 1 or more teeth, and with or Desire (%) 2 98 23 206
without removable dentures, are presented in Table 3. Total (%) 7 93 100 911
This group had a significant increase in desire for *Possible need = Missing 1 or a few teeth and not replaced or wearing
removable denture(s).
implant treatment between 1989 and 1999, whereas
there was no significant increase among those with- Chi-squared = 9.33; degrees of freedom 1; P < .001; odds ratio 4.36
(95% confidence interval 1.612.2).
out such a need. Of the total cohort, 92% had changed
their minds in 1999.
Cost was the major reason for not choosing im-
plants among subjects who reported that 1 or a few
teeth were missing and had not been replaced and Increasing knowledge of implants may have had an
among those with removable denture(s). No significant impact on clinicians practice profiles. In 1989, few
changes were observed between 1989 and 1999. The practitioners in Sweden with board certification in
subjects were asked if they wanted to replace their prosthodontics or had received mandatory additional
missing teeth/removable dentures with dental im- training were allowed to perform the restorative part of
plants. Those who responded that they had no interest the implant treatment within the dental insurance sys-
in implant treatment were asked to indicate the rea- tem. By 1999, all clinicians were allowed to perform im-
son(s) why, and several response alternatives were plant treatment, including the surgical part, within the
given (Table 4). insurance system; this may have influenced clinicians
to inform patients about this option. During the last
Discussion decades, there has been a clear trend to involve the
patient in the prosthodontic treatment planning process.7
The main result from the present study was a huge This has resulted in a more patient-oriented decision-
increase in interest for implant treatment from 1989 to making process using the emancipatory perspective in
1999. In 1999 almost all (94%) of the study population which the patient-practitioner dialogue is of utmost
expressed desire for implant treatment, a strongly sig- importance to achieve an optimal treatment outcome.1
nificant increase. However, clinicians may still play a dominant role in the
information and decision-making process in implant
Changes in Desire dentistry.8
The overall desire for a better oral healthrelated
The strong and significant change in desire for implant quality of life has become a reality in dentistry. Further,
treatment for the entire panel, as well as for different there is evidence that a high interest in esthetic den-
subgroups, may be explained by increased knowledge tistry and tooth bleaching among patients could be
about implant treatment. It is likely that most individ- related to television commercials publicizing new cos-
uals had a better knowledge about dental implants in metic treatment options.9 This could be related also to
1999 compared with the situation 10 years earlier be- innovations that focus on consumption, which could
cause of newspaper articles and information provided promote an increased interest, especially among the
by dental practitioners. young, wealthy, and well educated.10

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Changes in Attitudes Toward Desire for Implant Treatment

Table 4 Percentage Distribution Among Respondents with Possible Need* Regarding Reason(s) Not to Choose
Implant Treatment
1989 1999

Response alternative Men (%) Women (%) Total % n Men (%) Women (%) Total % n

Cost for treatment 45 55 15 256 44 56 34 566


Too invasive 37 63 5 75 35 65 6 107
Afraid of surgery 33 67 3 55 22 78 9 142
Afraid of side effects 40 60 3 48 32 68 11 177
*Possible need = Missing 1 or a few teeth and not replaced or wearing removable denture(s).
1989: Chi-squared = 14.42; degrees of freedom 3; P < .006. 1999: Chi-squared = 28.12; degrees of freedom 3; P < .0001.

The results of the study indicate a great increase in appears that those with a removable prosthesis have
desire for implant treatment for those with a possible a lower expectation and demand for oral function and
treatment need. This could support the assumption esthetics, and that satisfaction with removable pros-
that an individuals need may turn from latent to man- theses may be a rationalization in which an attitude
ifest, when previously unrealistic treatment options could develop through behavioral change.17,18
become available. New desires will emerge.1
Reasons for Not Choosing Implants
Edentulism and Desire for Implants
In the questionnaires, there were also questions that
Among the 111 individuals who reported having no nat- evaluated reasons for not choosing implant treatment.
ural teeth, with or without removable dentures, the re- The structure of the gatekeeping processes determining
sponse rate was only 42%. The number of respondents an individuals choice was discussed in an earlier study.4
was sufficient to permit some conclusions; 47 persons Such processes are multifactorial. For example, there can
allowed a precision of about 15%. This rather small be combinations of problems of oral health and quality
group had a lower increase in desire compared to the of life, psychologic factors and health beliefs, social
total panel. This could be the effect of several socio- structure and demographics, and economic factors.
economic gatekeeping processes.11 Individuals with less In the second study, more individuals with 1 or a few
education and low income tend to have poorer dental missing teeth that had not been replaced and those
status, in part because of poor finances, and edentulism wearing removable dentures expressed interest in
is often associated with poverty and deprivation.12 It is choosing implants compared with the situation 10 years
likely that some individuals do not even consider treat- earlier. This could indicate that when a treatment op-
ments they know they cannot afford. In such situations, tion has become a realistic alternative and is conceiv-
the desire for treatment does not change from latent to able, patients are more motivated to make a final de-
manifest. The national dental insurance system in cision regarding whether or not to choose treatment.
Sweden was introduced in 1974, with the intention to Cost was the major reason for not desiring implant
help all citizens afford necessary treatment, especially treatment, but also the percentage of those who
expensive prosthodontic care. However, the results of reported that they were afraid of surgery and afraid
the present study clearly indicate that several edentu- of unknown side effects had increased slightly over the
lous individuals are still unable to afford implant-sup- 10-year period. A study of Walton and MacEntee
ported prosthodontics. It is obvious that although showed that the most common reason for refusing free
Sweden has a general dental insurance system, there treatment with implant-supported mandibular den-
are still orally handicapped individuals who are not tures was concern about surgical risks.15 Dental anxi-
able to benefit from implants because of the high costs. ety appears to be an important gatekeeper in dentistry
Another possible explanation could be that older among many patients.19 In the present study, women
individuals who are accustomed to wearing dentures were more concerned about implant surgery and the
have little or no interest in implant treatment.13 Studies risk of unknown side effects of implants (Table 1). Such
indicate that a large number of patients (65% to 90%) a gender variation has been discussed in other prostho-
are satisfied with the functional aspects of their den- dontic studies.20,21
tures, often in spite of technical imperfections identi-
fied by dental professionals.14,15 There is also evidence Validity
that removable prostheses are preferred among those
who have few or no remaining teeth, compared with A validation study was performed earlier among the sub-
those who have only 1 or a few missing teeth.16 It jects in the 1989 questionnaire showing high agreement

484 The International Journal of Prosthodontics


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Narby et al

between self-reported and clinically observed number References


of missing teeth, replaced teeth, and removable den-
tures.22 This was in accordance with another validation 1. Narby B, Kronstrm M, Sderfeldt B, Palmqvist S. Prosthodontics
and the patient: What is oral rehabilitation need? Conceptual
study on congruence between clinical findings and
analysis of need and demand for prosthodontic treatment. Part 1:
patients self-reported oral status.23 In the present study, A conceptual analysis. Int J Prosthodont 2005;18:7579.
the focus was not on self-reported dental conditions but 2. Beazoglou T, Brown LJ, Heffley D. Dental care utilization over time.
on attitudes and opinions regarding need and demand, Soc Sci Med 1993;37:14611472.
which may have even better validity because the sub- 3. Narby B, Kronstrm M, Sderfeldt B, Palmqvist S. Prosthodontics
and the patient. Part II: Need becoming demand, demand becoming
jects are reporting their opinions. The nonresponse rate
utilization. Int J Prosthodont 2007;20:183189.
should be less important when studying changes in 4. Basker R, OMullane DM. Removable prosthodontic services re-
attitudes over time among the same individuals in a lated to need and demand. In: wall B, Kyser AF, Carlsson GE
cohort on 2 different occasions. Changes in attitudes are (eds). Prosthodontics. Principles and Management Strategies.
principally intraindividual, since the panel included the London: Mosby-Wolfe, 1996:223235.
5. Palmqvist S, Sderfeldt B, Arnbjerg D. Dental conditions in a
same individuals on both occasions.
Swedish population aged 4569 years. A questionnaire study.
The results of the present study should be inter- Acta Odontol Scand 1991;49:377384.
preted with some caution. Questionnaires may not, of 6. Kronstrm M, Palmqvist S, Sderfeldt B. Changes in dental con-
course, provide all the answers when evaluating actual ditions during a decade in a middle-aged and older Swedish
desire for implant treatment. In some aspects the ques- population. Acta Odontol Scand 2001;59:386389.
7. Kronstrm M, Palmqvist S, Sderfeldt B, Carlsson GE. General den-
tions were hypothetical, and the responses should be
tists attitudes toward delegation, information, and patient influ-
assessed with that in mind. However, the magnitude of ence in a prosthodontic context. Int J Prosthodont 1999;12:4550.
changes in attitude seems to be unambiguous, and the 8. Tepper G, Haas R, Mailath G, et al. Representative marketing-
expressed desire for implant treatment could be seen oriented study on implants in the Austrian population. I. Level of
as a result of changes in society, with new standards information, sources of information and need for patient infor-
mation. Clin Oral Implants Res 2003;14:621633.
of esthetics, new cosmetic treatment options, and
9. Theobald AH, Wong BK, Quick AN, Thomson WM. The impact of
desire for a better oral healthrelated quality of life, the popular media on cosmetic dentistry. N Z Dent J 2006;102:5863.
rather than of self-perceived functional need. 10. Johnsson M. Diffusion of Knowledge and Medical Practise [thesis].
Uppsala, Sweden: Uppsala University, 1986.
Conclusion 11. Grytten J. The effect of the price of dental services on their demand
and utilisation in Norway. Community Dent Health 1991;8:303310.
12. Gratrix D, Holloway PJ. Factors of deprivation associated with den-
This study shows that almost all surveyed individuals tal caries in young children. Community Dent Health 1994;11:6670.
expressed desire for implant treatment in 1999, which 13. Salonen MA. Assessment of states of dentures and interest in im-
is a major increase in interest compared with the find- plant-retained prosthetic treatment in 55-year-old edentulous
ings in the 1989 study. Individuals with a possible treat- Finns. Community Dent Oral Epidemiol 1994;22:130135.
14. Berg E. Acceptance of full dentures. Int Dent J 1993;43:299306.
ment need showed a great change in desire for implant
15. Walton JN, MacEntee MI. Choosing or refusing oral implants:
treatment, pointing out the fact that when an individ- A prospective study of edentulous volunteers for a clinical trial. Int
uals need alters from latent to manifest, the treatment J Prosthodont 2005;18:483488.
desire changes even more. 16. Bagewitz IC, Sderfeldt B, Palmqvist S, Nilner K. Social equality and
Cost was the major gatekeeper for not expressing dental conditions: A study of an adult population in Southern
Sweden. Swed Dent J 2000;24:155164.
desire for implant treatment. Costs, along with uncer-
17. McGrath C, Bedi R. Can dentures improve the quality of life of
tainty about risks and physical and technical prereq- those who have experienced considerable tooth loss? J Dent
uisites, are among the factors that apparently can 2001;29:243246.
influence a patients choice of prosthodontic treatment. 18. Davis EL, Albino JE, Tedesco LA, Portenoy BS, Ortman LF.
The findings in the present study are in agreement Expectations and satisfaction of denture patients in a university
clinic. J Prosthet Dent 1986;55:5963.
with those in previous articles in this series, where it is
19. Freeman R. Barriers to accessing dental care: Patient factors. Br
inferred that there is no true objective or subjective Dent J 1999;187:141144.
need and demand, especially in prosthodontic treat- 20. Trulsson U, Engstrand P, Berggren U, Nannmark U, Brnemark P-I.
ment. Manifest need and demand change over time Edentulousness and oral rehabilitation: Experiences from the
and are influenced by the patients attitude and situa- patient perspective. Eur J Oral Sci 2002;110:417424.
21. McGrath C, Bedi R. Gender variations in the social impact of oral
tion and the clinicians practice profile. True need can
health. J Ir Dent Assoc 2000;46:8791.
only be identified in a dialogue between the profes- 22. Palmqvist S, Sderfeldt B, Arnbjerg D. Self-assesment of dental
sional and the patient. conditions: Validity of a questionnaire. Community Dent Oral
Epidemiol 1991;19:249251.
Acknowledgment 23. Unell L, Sderfeldt B, Halling A, Paulander J, Birkhed D. Oral dis-
ease, impairment, and illness: Congruence between clinical and
questionnaire findings. Acta Odontol Scand 1997;55:127132.
This study was supported by The Public Dental Health Services, Uppsala
County Council, Sweden.

Volume 21, Number 6, 2008 485


Factors Explaining Desire for Dental Implant Therapy:
Analysis of the Results from a Longitudinal Study
Birger Narby, LDSa/Ingrid Collin Bagewitz, DDS, PhDb/Bjrn Sderfeldt, PhD, DrMedScc

Purpose: The aim of this research was to investigate possible factors behind the
desire for and changes in attitude toward implant treatment in a population of middle-
aged and older individuals in Sweden. Materials and Methods: In 1989 and 1999,
questionnaires were sent to 3,000 residents in rebro County, Sweden. Response
rates were 79% and 68%, respectively. Those responding to both questionnaires
yielded a longitudinal study panel. Logistic regression models were done with desire
of implant treatment and changes in desire of implant treatment as dependent
variables. Results: Older people, non-city residents, and those with one or several
missing and unreplaced teeth changed their desire for implant treatment between
study years. Effects of age, residence, and better dental status disappeared during
the 10-year study period. Those who were edentulous and those with removable
dentures (pseudo R2 : 0.17) expressed lower desire for treatment than those with all
teeth remaining or only one or a few teeth missing (pseudo R2 : 0.24) in 1989. High
income significantly increased the probability to desire implant treatment for the study
panel at both study occasions (P = .016 and P = .034 for 1989 and 1999, respectively).
Conclusions: Factors influencing desire for implant treatment were primarily income
and dental status. The influence of young age, urban living, and dental status regarding
the subgroup with one or several teeth missing in relation to those with all their teeth
disappeared during the 10-year study period. Int J Prosthodont 2011;24:437444.

I n recent decades, treatment with dental implants


has been established as the most important compo-
nent in the range of prosthodontic treatment. Dental
rehabilitation need in comparison with assessment by
patients.2,3
Analysis of changes in need and demand for im-
implants have made dramatic improvements in oral plant treatment is of great interest because of chang-
rehabilitation possible, especially for edentulous es in society and the differences in need assessment
individuals. between patients and dentists, but to the authors
The need and demand for prosthetic treatment, knowledge, this has not been researched in longitu-
especially implant treatment, has at the same time, dinal studies. According to a previous study based on
and in line with the development of society, changed two questionnaires, there was, over the course of a
for many individuals. In most Western societies, a decade, a dramatic escalation in interest of implant
shift into a demand-driven approach in health care treatment. At the time of the second survey, 95% of
is being witnessed.1 The overall desire for better participants expressed desire for implant treatment in
oral healthrelated quality of life has become a real- comparison with 39% in the first survey.4 The objec-
ity in prosthetic dentistry, although studies indicate tive of the present study was to construct multivariate
that need as assessed by dentists overestimates the models to find possible factors explaining desire for
implant treatment and possible factors explaining the
change in desire for implant treatment over the 10-
aSenior Consultant, Department of Prosthetic Dentistry, Public year study period.
Dental Health Service, Uppsala, Sweden.
bSenior Consultant, Department of Prosthetic Dentistry, Public
Materials and Methods
Dental Health Service, Malm, Sweden.
cProfessor and Chair, Department of Oral Public Health, Malm

University, Malm, Sweden. Two questionnaire studies were performed, one in


1989 and the other in 1999, with the intention of eval-
Correspondence to: Dr Birger Narby, Department of Prosthetic
Dentistry, Public Dental Health Service, Box 1813, S-751 48 Up-
uating desire for implant treatment among the same
psala, Sweden. Fax:+46 18 692947. Email: birger.narby@lul.se 3,000 subjects aged 45 to 69 years in rebro County,

Volume 24, Number 5, 2011 437


2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Factors Explaining Desire for Dental Implant Therapy

Sweden. Participants who responded in both 1989 If you, who have all of your own teeth left, would lose
and 1999 constituted the panel used in the pres- all of your teeth in one arch, what treatment would
ent study and accounted for 56% of the total survey you prefer? (four choices, with implants as one of
sample in 1989. The study group has been presented them)
in previous publications.5,6 A nonresponse analysis
was presented previously. When comparing those The questions aimed to address respondents with
who responded only in 1989 with those participat- various types of dental statuses.
ing in both 1989 and 1999, there were significant Those who responded that they would choose
differences between the groups. Subjects who re- dental implants were considered as having a possible
sponded on both occasions compared to those who desire for such treatment.4 Choosing dental implants
responded only in 1989 were younger, had a higher was set as the dependent variable in the regression
level of education, and reported better dental sta- models.
tus, ie, fewer participants wore removable dentures. The following variables from the questionnaires
Internal nonresponse varied for different questions, were used as independent variables in the present
which means different n values for different analy- study:
ses. Among those responding in both 1989 and 1999,
however, no significant differences in dental condi- Age in years (three categories): 45 to 49 years, 50
tions were noted between nonresponse groups and to 59 years, 60 to 69 years (in 1989)
other subjects.7 Individual income (divided into eight equidistant
The questionnaire, among other things, aimed at groups): < 100,000 SEK, 101,000 to 150,000 SEK,
measuring dental conditions and opinions regarding 151,000 to 200,000 SEK, 201,000 to 250,000 SEK,
dental implants and gaining information about demo- 251,000 to 300,000 SEK, 301,000 to 350,000 SEK,
graphics, social structure, oral healthrelated qual- 351,000 to 400,000 SEK, > 401,000 SEK
ity of life, desire for various types of prosthodontic Sex: male, female
treatment, and psychologic factors of interest. The Marital status: married and cohabitants, single
variables used in the questionnaire were published Education: low ( 9 years), medium (10 to 12 years),
previously.5 The validity of answers with regard to high (> 12 years)
dental conditions was analyzed in a previous study.8 Place of residence: city, village or rural
Questions related to the subjects dental condi- Dental status (in four categories): all teeth left, ie,
tions and desire for implant treatment were posed. all teeth remaining or all missing teeth replaced by
Participants missing one or more teeth not being fixed partial dentures (better dental status); one or
replaced and those completely edentulous with or several teeth missing, ie, one or several teeth miss-
without removable dentures were, in the present ing and not replaced by fixed partial dentures (me-
study, considered as having a possible treatment dium dental status); removable denture, ie, wearing
need. A hypothetical demand in this study is de- removable partial denture(s) and not edentulous in
scribed as desire for implant treatment. The follow- any arch (bad dental status); completely edentu-
ing questions were addressed to gauge desire for lous in one or both arches, ie, edentulous in one or
implant treatment: both arches and wearing or not wearing a denture
(bad dental status)
You, who are missing teeth in one arch, totally or Dental care delivery system: private practice, pub-
partially, would you in general prefer treatment with lic dental health system
dental implants, if possible? (yes, no, uncertain)
You, who are missing some teeth and have a re- Frequencies for the different variables are shown
movable partial denture, would you instead prefer in Table 1. Internal nonresponse varied for different
treatment with dental implants, if possible? (yes, questions, listwise deletion of missing data, which
no, uncertain) means different n values for different questions. The
You, who are missing all of your own teeth in one or frequencies were calculated from the questionnaire
both arches with or without removable denture(s), in 1989 since they changed little during the period.
would you instead prefer treatment with dental im- Implant desire, however, was calculated from the
plants, if possible? (yes, no, uncertain) questionnaire in 1999 because these values were rel-
If you, who have all of your own teeth left, would evant for the present study.
lose one or a few teeth, what treatment would There were also two attitudinal scales, in seven
you prefer? (four choices, with implants as one of steps, that were dichotomized in the analysis9: impor-
them) tance of dental function (unimportant to important)

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Narby et al

Table 1 Frequency Distribution of Respondents in


1989 and Implant Desire in 1989 and 1999 and importance of good dental appearance (un-
n Total non-
important to important). These scales are shown
% n (total) respondents in Table 2 together with the variables for age and
Sex income.
Men 48 1,136
Statistical Analysis
Women 52 1,247 2,383 617
Education Three different logistic models were used to analyze
< 9y 75 1,761 the responses for those participating in 1989 and in
1012 y 11 265 1999 and for analysis of the differences in responses
> 12 y 14 326 2,352 648 between those who participated in both 1989 and
1999.10 The effect of independent variables was ex-
Marital status
pressed as odds ratios. Nagelkerke (pseudo) R2, clas-
Single 79 1,877
sification plots, and correctly predicted cases were
Other 21 491 2,368 632 calculated for determination of goodness of fit of the
Place of residence models. The same model was used for analysis of
City 56 1,332 nonresponders (individuals who did not respond to
Rural 44 1,042 2,374 626 the question who desired implants). Frequency distri-
butions were calculated for the various measures. The
Dental category
statistical significance of differences was determined
All teeth remaining 34 794
using the Pearson chi-square test with P < .05 as the
One or several teeth 43 1,007 significance level. All calculations were completed
missing
using SPSS 11.0 (SPSS).
Removable denture(s) 7 166
Completely edentulous 16 380 2,347 653 Results
in one or both arches
Dental care delivery system A logistic regression model was constructed with
Private practice 79 1,749 the dependent variable as respondents stating a de-
Public dental health 21 472 2,221 779 sire, in contrast to those without a desire, for implant
service treatment in 1989. It showed a significantly higher
Implant desire (1989) probability for desire of implant treatment for the in-
No 68 1,614 dependent variables higher income, younger age,
Yes 32 769 2,383 617
better dental status, urban living, and concern for
a good dental appearance (Table 3). Income had the
Implant desire (1999)
strongest association with desire for implant treat-
No 5 79 ment. There was a 7% higher probability to desire
Yes 95 1,384 1,463 1,537 implant treatment between each of the 8 equidistant
groups, giving a total 56% higher probability to desire
implant treatment for those with the highest level of
income than for those with the lowest level.
Table 2 Frequency Distribution of Respondents in An association between desire for implant treat-
1989 for Age, Income, and Attitude ment and dental status was, however, not expected.
n Total non- Those with a higher objective need, ie, those with
Mean SD (total) respondents removable dentures and those who were edentulous,
Income 8 equidis- 5.42 2.84 2,112 888 had a lower probability of desiring implant treatment
tant steps than all other categories of dental status (Table 3).
Age Continu- 57.70 7.55 2,383 617 A logistic regression model was constructed for
ous
the population responding in 1999 with the depen-
Importance 7 steps 2.91 1.64 2,241 759 dent variable as respondents desiring implant treat-
of dental
function ment in contrast to others (Table 4). High income still
increased the probability to desire implant treatment
Importance of 7 steps 4.37 1.91 2,053 947
good dental for the total population. There was also no change
appearance in association as to dental status. However, there
SD = standard deviation. was a change in desire for implant treatment for

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Factors Explaining Desire for Dental Implant Therapy

Table 3 Logistic Regression Model With Respondents Stating a Desire for Implant Treatment in Contrast to
Those Without a Desire for Implant Treatment in 1989 as the Dependent Variable
Total a b
Independent variables OR P OR P OR P
Income (8 equidistant steps) 1.07 .016 1.05 .090 1.16 .039
Sex (female; male ref cat) 1.10 .459 1.07 .656 1.31 .419
Single (married or cohabitant ref cat) 1.01 .964 1.00 .997 1.01 .980
Education (< 9 y ref cat)
1012 y 1.10 .580 0.84 .294 0.58 .518
> 12 y 1.16 .364 0.91 .633 1.01 .993
Age (y) (continuous) 0.96 .000 0.97 .000 0.95 .014
Place of residence (city ref cat) 0.77 .029 0.81 .096 0.57 .052
Dental status (all teeth left ref cat)
One or several teeth missing 0.28 .000 0.28 .000
Removable denture(s) 0.37 .000 0.75 .340
Completely edentulous in one or both arches 0.24 .000
Public dental care delivery system (private practice ref cat) 0.87 .318 1.03 .879 0.41 .014
Importance of dental function (7 steps) 1.05 .142 1.05 .187 1.06 .478
Importance of dental appearance (7 steps) 1.07 .035 1.07 .036 1.03 .713
Total: n = 1,691 (nonrespondents = 1,309); a = respondents with all teeth remaining or missing teeth replaced by fixed prosthodontics or not
replaced at all (n = 1,336, nonrespondents = 465); b = respondents wearing removable partial denture(s) or edentulous in one or both arches
(n = 355, nonrespondents = 191); OR = odds ratio; ref cat = reference category.
Total: correctly predicted cases: 71.4%, 7.2% improvement; model 2: 274.9, P < .001, 13 df; Nagelkerke R2: 0.21.
a: correctly predicted cases: 68.9%, 9.0% improvement; model 2: 195.2, P < .001, 11 df; Nagelkerke R2: 0.18.
b: correctly predicted cases: 80.6%, 0% improvement; model 2: 36.0, P < .001, 11 df; Nagelkerke R2: 0.15.

Table 4 Logistic Reression Model With Respondents Stating a Desire for Implant Treatment in Contrast to
Those Without a Desire for Implant Treatment in 1999 as the Dependent Variable
Total a b
Independent variables OR P OR P OR P
Income (8 equidistant steps) 1.16 .034 1.21 .025 1.00 .995
Sex (female; male ref cat) 1.82 .086 1.98 .116 1.79 .413
Single (married or cohabitant ref cat) 0.83 .608 0.80 .597 1.02 .979
Education (< 9 y ref cat)
1012 y 1.13 .805 0.64 .434 12.67 .029
> 12 y 0.98 .990 1.69 .551 5.71 .214
Age (y) (continuous) 1.01 .695 1.03 .269 0.95 .276
Place of residence (city ref cat) 1.08 .792 1.05 .902 1.34 .606
Dental status (all teeth left ref cat)
One or several teeth missing 0.78 .504 0.80 .510
Removable denture(s) 0.21 .002 0.37 .104
Completely edentulous in one or both arches 0.11 .000
Public dental care delivery system (private practice ref cat) 0.69 .255 1.42 .488 0.22 .010
Importance of dental function (7 steps) 1.06 .561 1.14 .305 0.90 .557
Importance of dental appearance (7 steps) 1.11 .164 1.08 .398 1.12 .430
Total: n = 1,023 (nonrespondents = 1,977). a = respondents with all teeth remaining or missing teeth replaced by fixed prosthodontics or not
replaced at all (n = 980, nonrespondents = 881). b = respondents wearing removable partial denture(s) or edentulous in one or both arches
(n = 103, nonrespondents = 443); OR = odds ratio; ref cat = reference category.
Total: correctly predicted cases: 94.5%, 0% improvement; model 2: 53.9, P < .001, 13 df; Nagelkerke R2: 0.15.
a: correctly predicted cases: 96.4%, 0% improvement; model 2: 14.2, P < .001, 11 df; Nagelkerke R2: 0.06.
b: correctly predicted cases: 81.6%, 3.9% improvement; model 2: 17.6, P < .001, 11 df; Nagelkerke R2: 0.24.

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Narby et al

Table 5 Logistic Regression Model with the Change Table 6 Logistic Regression Model Regarding
of Desire for Implant Treatment from 1989 to 1999 Nonrespondents of the Question on Implant Desire in
as the Dependent Variable 1999 in Contrast to Respondents of the Same Question
Independent variables b OR P
in 1989 as the Dependent Variable

Income (8 equidistant steps) 0.01 1.01 .740 Independent variables b OR P

Sex (female; male ref cat) 0.11 1.12 .501 Income (8 equidistant steps) 0.11 1.11 .000

Single 0.10 0.91 .589 Sex (female; male ref cat) 0.28 1.32 .038
(married or cohabitant ref cat) Single 0.48 0.62 .001
Education (< 9 y ref cat) (married or cohabitant ref cat)

1012 y 0.07 0.93 .715 Education (< 9 y ref cat)

> 12 y 0.25 0.78 .204 1012 y 0.37 1.44 .048

Age (y) (continuous) 0.03 1.04 .001 > 12 y 0.43 1.54 .019

Place of residence (city ref cat) 0.31 1.36 .035 Age (y) (continuous) 0.04 0.96 .000

Dental status (all teeth left ref cat) Place of residence (city ref cat) 0.13 0.88 .267

One or several teeth missing 1.39 4.01 .000 Dental status (all teeth left ref cat)

Removable denture(s) 0.50 1.65 .135 One or several teeth missing 0.01 1.01 .959

Completely edentulous in one or 0.05 0.95 .875 Removable denture(s) 0.89 0.41 .000
both arches Completely edentulous in one or 1.38 0.25 .000
Public dental care delivery system 0.01 1.00 .988 both arches
(private practice ref cat) Public dental care delivery system 0.11 0.90 .429
Importance of dental function 0.03 0.97 .476 (private practice ref cat)
(7 steps) Importance of dental function 0.06 0.94 .082
Importance of dental appearance 0.02 0.98 .552 (7 steps)
(7 steps) Importance of dental appearance 0.02 1.02 .617
Total: n = 1,012 (nonrespondents = 1,988); OR = odds ratio; (7 steps)
ref cat = reference category. Total: n = 1,691; OR = odds ratio; ref cat = reference category.
Correctly predicted cases: 66.9%, 13.3% improvement; Correctly predicted cases: 69.5%, 9% improvement; model 2:
model 2: 140.09, P < .001, 13 df; Nagelkerke R2: 0.17. 295.67, P < .001, 13 df; Nagelkerke R2: 0.22.

those wearing removable partial dentures or eden- both occasions were younger, had a higher level of
tulous in one or both arches. For this subgroup, the education, and reported better dental status, ie, few-
independent variables dental care delivery system er participants wore removable dentures than those
and education level showed a significantly higher who responded only in 1989. Also, women and those
probability to desire implant treatment for those at- who were married or cohabitants had a higher degree
tending private practice and for those with medium of responding to both questionnaires.
education level.
The final logistic regression model was done with Discussion
the responses to the question about desire for implant
treatment from 1989 in contrast to the responses to The findings in the present study show that older peo-
the same question in 1999 (Table 5). Young age, ur- ple in comparison with other age categories, those liv-
ban living, and better dental status showed a higher ing in village or rural areas in comparison with those
probability for desire for implant treatment in 1989 living in cities, and those with one or several teeth
than in 1999. missing that were not replaced in comparison with
In 1999, there was a relatively high nonresponse those with all teeth remaining or replaced by fixed
for questions regarding implant desire (21%). In 1989, partial dentures had changed their mind regarding
the largest internal nonresponse was seen for ques- desire for implant treatment.
tions regarding importance of good dental appear- As stated in a previous study in this series of pa-
ance (14%) and income (11%). When comparing those pers, there was an immense increase in interest for
who responded only in 1989 with those participating implant treatment from 1989 to 1999.5 In 1999, almost
in both 1989 and 1999, the nonresponse analysis all (95%) of the study population expressed desire for
showed that there were some differences between implant treatment, a strongly significant increase and
the groups (Table 6). Subjects who responded on the main finding in this series of studies.

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Factors Explaining Desire for Dental Implant Therapy

The responses from the questionnaire in 1999 Cost, together with dental status, is a well-known
showed that the independent variables income and barrier in the gate-keeping behind utilization of dental
dental status had a significant impact on the prob- care, especially for fixed prosthodontic services.1719
ability to have a desire for implant treatment among Individuals with low incomes have a lower level of
the total study group. utilization and spend less money on dental care com-
Dental status had a significant impact on ex- pared with individuals with higher incomes.20 This,
pressed desire at both study time periods. Somewhat although to a lesser extent, also holds in subsidized
surprising was that those with a higher objective systems.21 The National Dental Insurance System in
need (those with removable dentures and those being Sweden was introduced in 1973 and has changed a
edentulous in one or both arches) had a lower desire number of times since. The relative cost for implant
for implant treatment in contrast to others. It seems treatment within the Swedish subsidized dental
obvious from the results of the present study that health care system did not decrease during the 10-
edentulous patients with removable dentures do not year study period; rather, it increased to some extent.
necessarily translate that condition into a desire for Income did not change as an important gate-keeping
implant treatment, which is in accordance with previ- factor between the two study groups.
ous studies.4,11 Participants missing one or more teeth It seems obvious that desire for implant treatment
not being replaced and those who were completely should decrease with increased age, but in 1999,
edentulous with or without removable denture(s) there were no longer any significant differences in
were, in this study, considered as having a possible age. Older people changed their minds regarding de-
treatment need, though it was not possible to distin- sire for implant treatment even though older individ-
guish between the absence of an anterior tooth or uals are said to be more reluctant about innovation.
molar on the basis of the information from the ques- One possible explanation to this change in the older
tionnaires. If this distinction had been possible, the cohort could be that implant treatment and its good
results could have been even more obvious, since results had become well known, especially among
participants missing an anterior tooth would probably older people where edentulism is more common.
desire a replacement more than someone missing a Other possible explanations could be that informa-
molar. However, the number of participants missing tion about implant treatment was addressed to eden-
a single molar was most likely very small considering tulous patients through newspapers, manufacturers,
the relatively high age of the participants. and dentists. More dentists had also adopted the
Objective need is less associated with dental care treatment option of dental implants and were more
utilization than subjective need.4 This is also in accor- comfortable with this treatment procedure. Supply
dance with the observation that there usually are great and information about implant treatment had thus
differences between provider and patient assess- increased. On the other hand, older people with re-
ments of quality of life, where patients usually regard movable dentures do not attend dental clinics as of-
their quality of life as better than providers do.12 Those ten as those with a better dental status and, thereby,
who need implant treatment the most, when assessed do not have the same information as individuals with
by dentists, do not desire implant treatment as much higher utilization of dental services. This could also
as those with all of their teeth remaining or with one or partly explain why the small edentulous group in the
a few teeth missing. The presence of ones own teeth present study had a lower probability to desire treat-
is a significant predictor for dental care utilization.13 ment compared to the total panel.
The rather small group of edentulous participants in During the past couple of decades, there has been
this study had a lower increase in desire compared to a clear trend to involve the patient in the prostho-
the total panel. This could be the effect of several so- dontic treatment-planning process.7 However, den-
cioeconomic gate-keeping processes.14 Many eden- tists may still play a dominant role in the information
tulous individuals have a low income, and it is likely and decision-making process in implant dentistry.22
that some individuals do not consider treatments they Stronger practice beliefs in certain treatment options
know they cannot afford, even if their oral healthrelat- give a higher rate of specific prosthetic utilization.23
ed quality of life would most likely benefit significantly Studies indicate that dentists opinions and clinical
from the use of dental implants.15 In such situations, judgments are of greater importance than research
the desire for treatment does not change from latent evidence in treatment planning and decision mak-
to manifest. Other reasons could include fear of dental ing.24 Demand is not only dependent on a manifest
treatment and worry about surgical treatments, but it need, but also on the information and availability of
could also be that people really are more satisfied with different treatment options.
their prostheses than the profession would consider.16

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Narby et al

Rural residence played a significant role in 1989 to respond to the questionnaire for every income
but not in 1999. The importance of place of resi- group. A higher response rate to the questionnaire
dence has in many ways been leveled out with the in 1999 would probably have increased the impact of
growth of mass communication. There is scarce evi- income even more.
dence for different ideals regarding appearance and A strength of this study is the longitudinal de-
oral healthrelated quality of life because of place sign, together with the use of multivariate analysis.
of residence. Studies indicate that the rural popula- Each effect of the independent variables is assessed,
tion is retaining more teeth and, consequently, may keeping the other variables constant, thus linking the
need and seek dental services more often than pre- individual patients outcome over time to the effect of
viously when there were pronounced differences in an independent variable. In this study, focus was on
dental status between different place-of-residence attitudes and opinions regarding need and demand,
cohorts.25 which may have a positive effect on validity. The non-
It has been shown that care organization influenc- response rate should be less important when study-
es both utilization and cost of care, resulting in higher ing change in attitudes over time among the same
cost and more frequent utilization for those receiv- individuals in a cohort at two different occasions.
ing private care.26 There might be a supplier-induced Changes in attitudes are principally intraindividual
demand, which means overconsumption of medical since the panel includes the same individuals at both
services, generated by the economic self-interest of occasions.
physicians who exaggerate patient needs.27 The re- The results of the study are over 10 years old, and it
sults in the present study indicate, however, that the may be questioned whether the results are therefore
difference in the Swedish dental care delivery system applicable today. To the authors knowledge, there has
between public dental health care and private prac- not been any major change in attitude toward implant
tice did not influence the desire for implant treatment, treatment since, nor has there been any considerable
except for in the subgroup with removable dentures. change in cost for the cohorts in this study. It seems
For this group, there was a significantly higher prob- as though the present study happened to occur dur-
ability for those attending private practice dental clin- ing a period where there was a dramatic change in
ics to have a desire for implant treatment compared attitude toward implant treatment. At the time of the
to those attending public dental health clinics. There second questionnaire, a vast majority expressed that
was also a significant difference regarding education they would consider and prefer implant treatment. To
for this same cohort with removable dentures. Those the authors knowledge, there has been little change
with medium (10 to 12 years) education had a signifi- in social priorities, meaning that a change back to
cantly higher desire for implant treatment than those less desire for implant treatment is unlikely. Moreover,
with low education. the purpose of this study was to discuss the factors
Oral healthrelated quality of life includes freedom behind the major change in attitude toward implant
of pain, optimal oral function, and good dental ap- treatment, and this has not altered recently.
pearance.28,29 Dissatisfaction with appearance has Further studies are important to provide greater
been found to be a major reason for transformation insight toward the influence of the number and loca-
of need into demand.30 There were no significant tion of missing teeth, as well as other factors such
changes in desire for these categories in the pres- as psychologic factors, possibilities to maintain oral
ent study. In 1989, there was a significant associa- hygiene, and fear of complications.
tion between importance of good dental appearance
and desire for implant treatment. This association Conclusion
was no longer significant in 1999, possibly because
the overwhelming majority of respondents expressed Manifest need and desire for implant treatment most
demand for implants, leaving little room for variation. likely changes over time. Factors influencing desire
Considering nonresponse, there was a clear bias for implant treatment are income and dental status.
in the response pattern. Point estimates are thus not Age, place of residence, and concern for dental ap-
reliable and probably too low, with underrepresenta- pearance no longer influenced desire for implant
tion of unmarried, low-educated men with bad teeth. treatment at the end of the studied 10-year period.
However, it is less probable that associations are bi- Individuals with removable dentures or those who
ased, and, if so, they are probably underestimated. were edentulous in one or both arches had a lower
Thus, analysis of the nonrespondents in 1999 indicat- probability to desire implant treatment than those
ed that some of the independent variables could be with all their teeth remaining or with missing teeth
underestimated. There was an 11% higher probability replaced by fixed partial dentures.

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Factors Explaining Desire for Dental Implant Therapy

Acknowledgment 15. Strassburger C, Keschbaum T, Heydecke G. Influence of im-


plant and conventional prostheses on satisfaction and qual-
This study was supported by the Public Dental Health Services, ity of life: A literature review. Part 2: Qualitative analysis and
Uppsala County Council, Sweden. evaluation of the studies. Int J Prosthodont 2006;19:339348.
16. Walton JN, MacEntee MI. Choosing or refusing oral implants:
A prospective study of edentulous volunteers for a clinical trial.
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V
A grounded theory on
importAnt fActors involved
in treAted pAtients decision-
mAking process for implAnt
therApy.

Birger narby, ddsa


Ulrika Hallberg, Ass. Profb
Ingrid Collin Bagewitz, DDS, Ph.Dc
Bjrn Sderfeldt, Ph.D, DrMedScd

a
Senior Consultant, Dept of Prosth. Dentistry, Public Dental Health
Service, Uppsala, Sweden
b
Associate Professor, Nordic School of Public Health, Gteborg,
Sweden
c
Senior Consultant, Dept of Prosth. Dentistry, Public Dental Health
Service, Malm, Sweden
d
Professor, Dept of Oral Public Health, Malm University, Malm,
Sweden

Reprint requests:
Dr. Birger Narby
Dept of Prosthetic Dentistry, Public Dental Health Service,
Box 1813, S-751 48 Uppsala, Sweden.
Phone:+46 18 6116380
Fax:+46 18 692947. E-mail: birger.narby@lul.se
Abstract
Aim: The aim was to describe a)the process leading to desire
for implant treatment and b)how patients missing teeth gained
information about implant treatment and also to c)identify
gatekeeping factors, and d)experiences in changes in oral health
related quality of life.

Methods: The constant comparative method for grounded theory was


used in collecting and analysing data. Ten informants participated in
the study, all treated with implant supported fixed dentures during
the last year.

Results: The emerging core category was that the participants


experienced a journey from social stigma to exhilaration. This
process ended up in the perspective that the participants new life
with dental implants indeed was very good and meant an end of
their social stigma, but had some gatekeepers before treatment
such as cost, and some aspects within dental anxiety. The dentists
opinion and suggestions was the most decisive part in the decision
making process and the trust in the dentist and his/her dental team
was crucial for the decision to undergo treatment, and for the whole
experience with the treatment. A great improvement in oral health
related quality of life was stated.

Conclusion: This qualitative study gives as the core category and


main finding the importance of the patients trust and confidence
in the dentist and his/her staff, in the process of transforming desire
for dental implant treatment into a manifest demand, and also in
making it more likely for the patients to become satisfied with the
treatment result regardless of complications.

Keywords: edentulousness, dental, implant therapy, need, demand,


grounded theory, decision-making
introduction
Edentulousness and the use of dentures have for most people a
pronounced impact on well-being and oral health related quality of
life.1 For edentulous individuals in particular, during the last thirty
years, the treatment with dental implants has made it possible for
dramatic improvements of oral rehabilitation.2 The need and demand
for prosthetic treatment, especially implant treatment, has changed
for many individuals at the same time which is in line with the general
development of society.3 The overall desire for a better oral health
related quality of life as well as desire for naturally looking dental
constructions have become realities in prosthetic dentistry, although
studies indicate that need, as assessed by dentists, overestimates
the rehabilitation need, in comparison with assessment done by
patients.4
The present paper is part of a larger study where the intention is to
evaluate need and demand for treatment with dental implants. Need
and demand are difficult to measure since prosthodontic treatment
is highly individual and not closely related to oral status.5 Need is
stated as socially established in the interaction between patient and
dentist. The professional attitude toward need must be that there is
no true objective or subjective need. Need is established only in a
communicative dialogue with mutual respect between the profession
and the patient. In the prosthetic treatment decision-making process,
the emancipatory perspective with the patient-dentist dialogue is of
utmost importance to achieve an optimal treatment result.
Need does not always lead to demand for treatment, nor to
utilization, depending on the gate-keeping processes between need
and demand and between demand and utilization. Demands must
be accepted through the knowledge that there is no objective need
and that demand depends on the patients opinion. The concept
gate-keeping refers to the social and psychological processes that
transform need into demand, and demand into utilization. These
factors are dependent on the patients opinion. Therefore, socio-
dental factors should be included and evaluated in studies on need
and demand for utilization of prosthodontic care.6
Still, many patients do not choose dental implants as a
rehabilitation opportunity. Our knowledge about the factors behind
these decisions is based on technical aspects7 and not on subjective
or psychological factors. There are few studies in this field and most
of them are derived from different questionnaires with only a few
questions concerning these topics.8 Individual opinions are difficult
or impossible to capture in the analysis of questionnaire studies.
Important aspects may be overlooked when it comes to the patients
perspective. A qualitative study method makes it easier to go deeper
into these issues, and to reflect opinions and results which may
be concealed from a quantitative study perspective. This study is
conducted according to the grounded theory which aims to develop
understanding and interpretation of the individuals description
of experiences rather than to tryt to seek the objective truth.
In the last decade, there has been an increasing interest to analyse
and describe the patients point of view, but only a few qualitative
studies have been presented with implant treatment in focus.9,24,26
The aims of the present study is therefore, by using the constant
comparative method for grounded theory, to a)describe the process
patients missing several or all teeth go through before getting treatment
with a fixed implant-supported denture,and also to b)describe how
the patients gained information about implant treatment, and the
process leading to desire for implant treatment. Another aims is to c)
identify gatekeeping factors which were important from the patients
perspective, and to d)identify the patients experience of changes in
oral health related quality of life after implant treatment.

methods
Qualitative method
The constant comparative method for grounded theory, originally
described by Glaser & Strauss (Modified grounded theory) was used
in collecting and analysing data.10,11 This qualitative method aims at
generating concepts, models, and theories, grounded in empirical
data. This method implies analysing, open, axial and selective
coding in order to create a structural formula in the analysis. The
basic principles of grounded theory include concurrent sampling
and analysis, constant comparisons, theoretical sensitivity, and
saturation. Saturation is reached when new interviews do not
bring additional information into the categories devised in the
earlier interviews.12 Grounded theory has developed in sociology
and is founded in symbolic interactionism, saying that meaning
is constructed and changed within interactions between people.
Perceptions of the world are individual and constantly interacting.13
Grounded theory is one out of approximately thirty qualitative
research methods and includes both induction and deduction, which
means constructing a hypothesis from the obtained data, making
conclusions with a starting-point from the hypothesis. Induction
is a main part in grounded theory, one difference to quantitative
research.
Criteria for judging the quality of a grounded theory study
include fit, relevance, modifiability, parsimony, and scope.14 Fit
means that the core category fits when it is relevant and integrates
other concepts, creating the emerging theory dense, saturated and
practically applicable. Relevance implies that the generated theory
should conclude important phenomena and is interesting to the
reader, and modifiability means that the theory could be adjusted
according to new data. Parsimony and scope concern the extension
of the emerging theory.
One assumption in qualitative research is that data are brought
forward in interaction between researcher and informant.12
Therefore, the relationship between these two subjects should be
paid attention to, because of its importance for the results. This
reflexivity includes that the researcher must identify preconceptions
which might bias the interview.15

Ethical aspects
The study design was supported by the Research Ethics Board at the
University of Uppsala, Sweden. Requirements concerning informed
consent and confidentially were promised and secured.

Study group
Ten informants (six women and four men; mean age 69 years, range
54-84 years) participated in the study. The informants were patients
at the Specialisttandvrden Kaniken, Folktandvrden (Specialist
Dental Care, Public Dental Health Services), Uppsala, Sweden, and
treated with implant supported fixed dentures according to well-
known and accepted procedures.16 The patients were all referred
from dentists in Uppsala County to a clinic with specialists in
prosthodontics and were strategically selected from the register
at the clinic on the basis of gender, age, and place of residence.
No consideration was paid to personal factors but all considered
themselves of good health although two had diabetes. The
socioeconomic factors were not included in the interview but could
be estimated to be averagely distributed. Their dental experience was
discussed in the interview but was not considered in the selection
of informants. In the pre-treatment discussion had all informants
received written information of estimated cost and at least at two
occasions information about risks for major complications and
about normal operative procedure. All of the informants were
treated with implant supported fixed dentures during the last year.
The cost for the implant treatment was subsidized according to the
National Dental Insurance System in Sweden. The intention with
this sampling procedure was to obtain a heterogeneous group to
maximize the variations of experiences in the group studied. The
dental situation of the informants is presented in Table 1.

Approach
An open, taped interview lasting up to one hour was conducted
with each subject in a quiet room on other premises than the clinic.
An interview guide was used, and the themes concerned 1) oral
function and dental status, daily living, and quality of life before
and after the treatment with an implant supported fixed denture, 2)
the relative importance of having confidence in the dentist and how
this is obtained, 3) gatekeepers as treatment cost, dental anxiety, or
others, 4) how the informant had obtained information of implant
treatment and 5) how the decision process started making a latent
desire manifest.
The interviewer was a prosthodontist (first author) with much
experience from dental implant treatment but without knowledge
of the informants and without involvement in their treatment. The
informants were informed that they could end the interview at
any point and had the opportunity to raise questions of relevance
to them. Each question theme gave the opportunity to a broader
discussion, as for a variety of potential gatekeepers. Data collection
and analysis were conducted after each interview and continued until
new interviews did not provide additional information. Saturation
was reached after 10 informants.
Procedure
After the selection of a presumptive informant from the patient
register, each subject was informed by letter about the study
and asked if they were willing to participate. Written and verbal
information concerning aim and procedure of the study was given to
all subjects. After a written consent, time for a taped interview was
scheduled with each individual.

Data analysis
The interviews were transcribed verbatim and analysed in open,
axial and selective coding processes.10,11 The process of open coding
ended up with clustering substantive codes with similar content
into summarizing categories, axial coding. Relationships between
categories were sought and data were put together. In the selective
coding, categories were saturated by additional information,
assessed by adding re-coded earlier assessed data. A core category
was identified, central in the collected data and related to the
subcategories.

Results
Taking part of a journey from social stigma to exhilaration
The core category emerged in the present study was that the
participants took part of a journey from social stigma to exhilaration
as seen as flowchart in table 2, where trust in the dentist and
confidence in the dentist and his/her team was a central part. This
illuminates the journey from deteriorated dental health with pain and
lowered self-esteem which resulted in social withdrawal e.g social
stigma, to the decision of going through with implants treatment, to
feelings of gratitude and feelings of becoming the person I once was.
This process ended up in a more realistic perspective that their new
life with dental implants indeed was very good and meant an end of
their social stigma.The process had however some gatekeepers such
as fear of pain, including the risk of having problems afterwards
with the implants, and costs.
The dentists opinion and suggestions was the most decisive part
in the decision making process and the trust in the dentist and his/
her dental team was crucial not only for the decision to undergo
treatment but also for the whole experience with the treatment. All
of the informants had considered the possibility of implant treatment
for some time. Some made their decision after having initially
discussed it within the family, others because of comments from
acquaintances, advertisements, or because the lack of taste when
eating, and of course the feeling of loose dentures. It was obvious
that the trust in the dentist and his/hers skills made a very important
part in the decision making process. An perhaps even bigger and
more important part was the possibility to discuss the treatment
options with the dentist, especially having the chance of discussing
their individual need for treatment. Some of the informants changed
dentist during this process because of lack of trust.
Only two gatekeeping factors were mentioned by the informants,
cost and dental anxiety although other potential gatekeepers were
discussed. Cost was considered as a gatekeeping factor of little
importance. All but one of the informants said that they would desire
and demand this treatment at almost any cost and were prepared to
take a bank loan, if necessary. A correct estimation of cost together
with a pronounced trust in the dentist seemed to be of importance
in the decision process.

He is a very skilled dental surgeon and I trust him completely.

Becoming an unsecure person


Experience decreasingly worsened oral health
The participants described a history of many years of deteriorated
oral health depending on different causes such as accidents, dental
anxiety and diseases. This deteriorated oral health caused physical
pain, infections and discomfort and it also caused difficulties with
for example chewing, and fear of cleaning their teeth because of the
risk of losing teeth. The participants point of view was that they
had done everything in their power to improve their dental status
over the years including both considerable economic efforts and also
considerable personal effort in trying to have good oral hygiene.
Despite all their efforts they experienced a deteriorating oral health
impossible to improve or cure. This deteriorating oral health also
lead to embarrassment in relation to others, the participants did not
want to be seen as messy or someone that does not take care of
their teeth owing to for example economical or ignorant reasons.
Therefore the participants withdraw from many social activities and
when they met others they tried to not show their teeth.
Id anxiety all the time, Id anxiety every morning, the first thing
was to feel with the tongue if anything was loose and you didnt
want to laugh too much or open the mouth.

Living in pain and anxiety


Finally the participants lost so many teeth or all teeth that they had
to wear dentures. But having dentures was even worse than the poor
oral health. The dentures caused physical pain and sourness and were
connected with feelings of shame and a variety of practical problems,
like anxiety for the denture falling out which also occurred, gagging,
and severe difficulties in chewing desired food. A major impairment
of the ability to sense different food tastes was also reported by
all the informants. The social consequences were massive for the
participants. They felt ashamed and did not tell anybody that they
had a denture except to their closest family.
A sense of powerlessness was reported by participants. They could
not do anything about their ability to adapt to their denture. The
sense of insecurity was common, with great reluctance to dine in
public restaurants or at home with friends, fear of the denture falling
out at work, difficulties with speech, and difficulty to breathe at
exercise. This gave as a very common and almost unanimous result
diminishing of their social contacts.

It was difficult all the time. I lost a kilo per week, I couldnt eat,
just couldnt, I gagged all the time, I couldnt be among people.

I couldnt sense any taste. My husband had to do all tasting


when I was cooking

Becoming a determined person


Desire for a better solution turn in to demand
The participants described how they finally felt a desire for a better
solution of their dental problems than wearing a denture. The life
situation with the denture was unacceptable with difficulties in
eating, social, physical and psychological problems. In line with this
the participants started to gather information about treatment with
dental implants, how and where to get it. For example they talked to
others that had already gone through with the treatment. They also
discussed this issue with their family and relatives.
The participants described the cost for dental implants as a
gatekeeping factor of little importance in the process of deciding
whether to have or not to have the implant treatment. The reason
for this seemed to be the confidence in the dentist and the belief in
having got a correct pre-treatment estimation of cost, and also having
had the possibility of discussing treatment options with their dentist.
Only one of the informants postponed the treatment for a couple of
years because of the cost. All of the others considered cost of little
importance and were prepared to take a bank loan, if necessary. In
the end of this process the desire for a better solution turned in
to a demand, they really wished going through with treatment with
dental implants.

I made up my mind because having a denture was no alterna-


tive. So I quit smoking and put those money aside, saving it for
the treatment cost.

Having trust in the dentist


It was of great importance for the participants to find a dentist they
could really trust regarding both medical skills and as a person. This
was true also for the dental team, the participants had a need for the
same feeling of trust in them as in the dentist. The feeling of being
involved in the treatment was important. Some of the participants
had changed from one dentist to another because of lack of trust
when discussing a possible dental implant treatment. The participants
knew about dental implant treatment since long through media, from
dentists or relatives, or by advertisements, but their definite decision
was made after discussion with their family and ultimately with their
dentist, where trust in the dentist was decisive.
Also dental anxiety for the treatment was seen as a minor problem
which also was considered dependent on their trust in the dentist,
although some of the patients in other circumstances had been very
reluctant to dental treatment because of anxiety for injections or
visible blood.

Trust in the dentist is the most important thing, yes it is. You
feel that this is right, wow, it was like a burden was taken from
my shoulders.
Going through with the treatment
When having to live with deteriorated dental health or with
dentures the participants did their outmost to hide their situation
from others.However, the participants seemed to have no problems
telling workmates or friends as soon as the implant treatment was
scheduled.
The participants were very satisfied with the result of the implant
treatment, feeling restored in oral function and aesthetics and giving
a regained self-confidence and self-esteem. Some of the participants
put the oral-facial aesthetics forward as the most important factor
for self-confidence. The totally dominant opinion was the feeling
that implant supported fixed partial dentures felt better than a
conventional fixed partial denture and was comparable to their
own natural teeth. The treatment outcome was described by all the
informants as a substantial improvement in oral comfort and in
quality of life even though some of the participants described pain
after the implant operation, and some had experienced difficulties
with implants which did not integrate, giving prolonged treatment
and re-operations. No one described this as giving any negative
influence on their opinion of the treatment, which they all considered
as a success. Those who had experienced disintegrated implants did
all blame themselves of causing this unsuccessful osseointegration.
No one considered this as a result of poor management from the
dentist.
Some of the participants described that they had dental anxiety
before the operations but no one considered the treatment as painful
or complicated although some informants lost implants and had to
be re-operated.

I read in the papers about Bengt Feldreich (Swedish celebrity), he


had made this operations and it came out very well. And he was
old at the time. And then I thought that if he could do it, I can.

Becoming the person I once was


Being free from the prison of pain and social stigma
The participants stated a great improvement/recovery in oral health
related quality of life and were readily prepared to recommend
implant treatment and their dentist to others in spite of some
complications. The participants said that their psychological,
physical and social wellbeing was considerably improved. They
claimed that they regarded their implant supported fixed dentures as
their own genuine teeth and that it felt and functioned physically as
their own natural teeth. For example, the ability of sensing different
food tastes which were highly diminished while wearing a removable
denture, according to all of the participants, was regained after the
treatment. The sense of regained security was very common, the
participants witnessed about being able to sneeze, cough, and their
social contacts were no longer restrained because of the fear of
dropping their denture while eating among others.
A couple of the participants put forward the lack of oral-facial
aesthetics when having dentures as highly important and felt that
they after the treatment had regained their looks and self-esteem.
A fixed implant-supported denture was compared with having own
natural teeth also when it came to aesthetics.

When you look yourself in the mirror and see all the tooth gaps
that really takes your self-esteem down, and now I feel like a
whole person, Self-esteem is totally dependent of aesthetics.
It was so fun getting my new teeth. The first thing I did on that
day was to go to a restaurant.

Having feelings of gratitude


All the participants spontaneously expressed gratitude to the dentist
and his/hers staff.
For those who had had recurrent infections, loose teeth, or badly
functioning dentures, the fixed implant supported denture gave the
patients the feeling of good dental status and of being orally healthy
for the first time for many years. They did not have to visit their
dentist as often as before and they were pain-free. The fixed dentures
felt as their own natural teeth and they felt orally healthy.

He should have applause

Its the best thing that has happened to me, ever.


Being caught by a more realistic perspective
Being hit by the pale cast of thought
Sometime after the treatment and the feelings of becoming the person
they once was and feelings of gratitude, the participants started to be
aware of minor negative side effects of the implants. When first asking
for any discomfort from the implant supported fixed dentures all the
participants expressed that the problems were very small. But when
discussing this further, most of the participants found it difficult to
keep optimal dental hygiene. Those informants who received a fixed
implant supported denture in the upper jaw reported difficulties in
speech. This seemed to diminish over time, though. Some felt that
they had too many teeth and that an increased saliva production had
become somewhat annoying. Most of the patients had accidently bit
their tongue or cheek at some times.

Im totally satisfied but its a bit difficult to keep the oral


hygiene up.
Its a bit difficult with the speech, and I get rather much saliva.

discussion
All of the informants in this study had experienced a deteriorating
dental status followed by a period of wearing a removable denture,
except one informant who did not have any teeth nor removable
denture. The consequences for the oral functions were severe and
made most informants reduce their social interactions and contacts.
Their image of themselves changed and they felt as deviating and
uncertain persons, similar to the results from another study by
Trulsson (Hallberg).9 Both this and our present study show how
informants with removable dentures developed avoiding strategies
in order to ensure that no one would notice the denture. In order
to manage uncertainty they often avoided social contacts, especially
when eating. These avoiding social contacts strategies contributed to
restricted social participation and a change in self-image.
The use of the grounded theory method in this study revealed the
importance of the patients trust in the dentist as the core category
and main finding. This trust seems to be vital to make the patient
choose, accept and go through with the treatment, perhaps even
more so making the patient more likely to be satisfied with the
treatment result. This expression of trust in the dentist was common
even from those informants who had experienced complications.
They thought themselves to be the cause of these complications, and
no one questioned the dentists skills or management.
The design of a qualitative study includes control of quality in all
phases from research question, research approach, data collection
and analysis. This study is based on an extensive amount of data,
more than 150 pages, from a heterogeneous group strategically
selected from the patient register. Data collection continued until
saturation was reached and no additional information was gained.
This sampling procedure is considered as being closely related
to internal validity.17 The emerging categories, describing trust
and confidence in the dentist, were all grounded in data and the
quotations given are intended to show the trustworthiness of our
interpretation. External validity concerns transferability to a new
context.17 Our opinion is that the results from this study could be
transferable to other groups treated with implant-supported fixed
dental prostheses with similar characteristics to our study group.
As stated in a previous study in this series of papers, there was a
huge increase in interest for implant treatment from 1989 to 1999.
Almost all (95%) of the study population expressed desire for
implant treatment in 1999, a strongly increase and one of the main
findings in this series of studies. This implies a high possibility that
the results from this present study could be applicable to a larger
extent.3 However, we do not in this study include patients not able
to be successfully treated with fixed implant prosthesis, nor did we
include informants who had to pay the full cost of the treatment.
It is important for qualitative studies to identify preconceptions
which might bias the interview. The interviews were conducted by
a dentist who could influence the patients answers. People might
answer a dentist differently than they do to e.g. a social scientist.
Dentists are often not very familiar with the interview technique
and not used to guide the interview with questions related to a
problem or a treatment. On the other hand, the dentist may be able
to go deeper into questions regarding treatment, and complications.
The results from this study show, in many aspects, similar results
as a study by Trulsson (Hallberg) et al where the interviews were
conducted by a social scientist.9 This indicates of a good validity
for the present study. In both studies, though, the patients were
referred to a specialist clinic which could mean a risk for bias. Most
of the patients were referred because the general practitioner did
not perform implant treatment and not because of any anticipated
specific treatment difficulty. This should mean that the patients in
many aspects are similar to most implant treatment patients.
The result in this study differs from the results of another
qualitative study that showed that patients with chronic periodontitis
shared the opinion that they had to depend on the care provider
independently, whether they agreed to the treatment plan or not. The
patients also had difficulties to foresee the result of the treatment.18
A conclusion from the study with these patients with periodontal
disease was the importance of giving thorough information about
the planed treatment and to give much attention to the patients
individual needs. In our study, the informants described information
regarding treatment and costs as very good, and also that there were
a thorough individual preparation before treatment giving a deep
trust in the dentist and the staff.
The differences in these studies can depend on several factors,
besides the eventual difference in information and mutual discussion
pattern. The trust in the dentist could also be the result of a long
treatment period and long treatment sessions, which most often is
the case in implant treatment. This has in other studies been shown
to have an impact of the patients relation to and experience of the
treatment result.19,20The possibility to freely discuss the treatment
options and to be given the opportunity of talking about psycho-
social factors has previously been put forward as important for
the subjective opinion of the prosthetic treatment.21 The patient
panorama could also be somewhat different in our study with
implant treatment patients compared to the other study with patients
with a periodontal disease. The treatment outcome could also in
many implant treatment cases be more easily described with a higher
degree of prognostic accuracy than for periodontal disease.
The oral-facial aesthetics seems to be of definitely higher
importance than good dental function for some of the informants,
which also has been described in other studies.22 These patients
expressed that their self-esteem and self-confidence were severely
depressed by having tooth gaps, even when they were only visible
for themselves. This is in accordance with another study where the
eventuality of losing a tooth or getting dentures was compared to
being unemployed .23 The informants in our study described the
feeling of being restored and regaining self-esteem when they once
again got fixed teeth.
The informants were asked if there were any obstacles, gatekeepers,
in the decision making process. The two factors mentioned were
cost and dental anxiety, but neither was described as of importance.
Two of the informants had hesitated for a period of time to choose
implant treatment because of the cost but had all the time been
determined to go through with the treatment later. Some of the
other informants had been prepared to take a bank loan but chose
not to while the total cost showed to be much less than they had
anticipated. This opinion that the total cost was not as high as they
thought was unanimous for all the informants. The pre-treatment
cost estimation showed to have good accuracy which strengthened
the confidence in the dentist and his/her staff. A weakness of the
study is that these patients had passed the gatekeeping process and
expressed demand.A study of needy patients not demanding implant
treatment would be of great interest but outside the scope of this
study.
However, a new regulation was introduced in the National Dental
Insurance System in Sweden a few years ago. The regulation permitted
highly subsidised treatment costs for prosthodontic services. The cost
for dental implant therapy is low in an international perspective. It
is likely that this might have an impact on the desire of implant
treatment although most of the informants declared that they would
desire this treatment regardless of cost and were prepared to take a
bank loan, if necessary A pointer of importance is though that the
participants in this study was referred to a specialist clinic with the
pronounced intention of having dental implant treatment and were
to some degree prepared for the cost and the different sections of the
treatment. Those without the economical prerequisite had probable
declined the offer of referral.
Some of the informants described having dental anxiety previously
but had gone through with the treatment without hesitation because
of the pre-treatment information which was considered very
accurate.
Cost and dental anxiety have earlier been discussed as important
and perhaps this is the case for many dental treatments, but not for
this study group. However, when asked if they knew of any friends
or acquaintances that had declined from implant treatment because
of cost or dental anxiety there seemed to be very few such cases.
Still, the gatekeeping may occur long before contact is taken with
dental care, which of course is not perceived in the care system,
even less in a specialist clinic. A recent qualitative study from Britain
among elderly emerged two main themes; patients fear and anxiety
(relating to the pain of surgery, complications of the procedure
and immediate post-surgical denture use), and the appropriateness
of the procedure in an elderly person. The impact of cost was not
included in this study. This difference compared to our study could
in part depend on age and cultural differences (appropriateness for
an elderly person). Our study group were younger and perhaps
are also implant treatment a more commonly accepted treatment
option in Sweden, regardless of age. Another reason for difference
could be that the informants in our study concerned treated patients
and had concluded their decision making process, and the reported
confidence in their dentist making dental anxiety a minor concern.24
Another study has claimed that implant supported fixed dentures
makes the patient regain health and function to a higher degree than
with fixed partial dentures or removable dentures.25 The results
in our study confirms this. This is also in line with yet another
qualitative study regarding eating indicating that implant supported
mandibular overdentures gave a significant improvement compared
to informants with adjusted prostheses.26 The informants in our
study unanimously declared the feeling that implant supported fixed
partial dentures felt better than a conventional fixed partial denture
and was comparable to their own natural teeth.
Everyone in the study group who had used a removable denture
(all but one), reported an obvious decrease of the ability to sense
food tastes. This effect of the removable denture was considered as a
clear decrease in quality of life. After receiving the implant supported
fixed denture, the ability of sensing food tastes was regained.
The percentage of elderly individuals without teeth and wearing
removable dentures has dramatically decreased in Sweden during
the last decades.27 On the other hand there is today a higher share
of the population getting older, and they will probably face the risk
of losing their teeth at a higher age. This is also proposed to be the
case in other parts of the industrialized world, e.g. in the United
States.28 This means that in a foreseeable future there will be many
patients with dentures and probably desiring for implant supported
dentures.
In line with the results from the present and other studies, it should
be politically urgent to make it possible for those of the denture
wearers who cannot accept their denture, to have the opportunity
to get subsidized dental implant treatment within the national
insurance system. Our study shows the importance of giving patients
the opportunity of regaining self-esteem and becoming the person
they once was with the feeling of social security, regained attraction
and a good dental status.

conclusion
The core category and main finding were the importance of the
patients trust and confidence in the dentist and his/her staff in the
process of transforming desire for dental implant treatment into a
manifest demand, and in making it more likely for the patients to
become satisfied with the treatment result regardless of complications.
Mutual discussions in the treatment planning process, primarily
good pre-treatment information, and accurate cost estimation
were reasons for developing this trust and confidence. Experienced
complications like disintegrated implants was not considered as a
result of bad management from the dentist, instead the participants
put the blame on themselves.
All of the informants had considered implant treatment for
some time and made their decision when they felt confident in the
dentist and after discussions with their family and with the dentist.
None of two identified gatekeeping factors, cost and dental
anxiety were important for the decision of getting implant treatment.
No other gatekeeping factors were put forward by the informants
in this study.
A great improvement/recovery in oral health related quality of life
was stated in terms of regaining the feeling of self-esteem and being
secure in social relations. The ability of sensing different food tastes
was also regained after implant treatment and the perception of the
implant supported fixed denture was the same as of own natural
teeth.

Acknowledgment
This study was supported by The Public Dental Health Services,
Uppsala County Council, Sweden.

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related quality of life and treatment goals among elderly adults. Australian
Dent J 2008; 53: 26-33.
2. Attard N.Z, Zarb G.A. Long term treatment outcomes in edentulous
patients with implant-fixed prostheses: the Toronto study. Int J Prosthodont
2004;17:417-424.
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toward desire for implant treatment: a longitudinal study of a middle-aged
and older Swedish population. Int J Prosthodont. 2008; 21:481-485.
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and Demand for Prosthodontic Treatment. Part 1: A Conceptual Analysis.
Int J Prosthodont 2005;18:75-79
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Patient: Part II: Need becoming demand, demand becoming utilization. Int
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7. Glantz P-O, Nilner K, Jendresen M.D, Sundberg H. Quality of fixed
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magnets. Clin Oral Implants Res 2009; 20: 1293-1298.
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Thousands Oaks, CA, USA: Sage 2000; 509-535.
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14. Glaser B. Theoretical sensitivity: advances in the methodology of grounded
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reflexitivety and relationality. Qual Health Res 2001; 11: 257-272.
16. Zarb G, Albrektsson T, Baker G, Eckert S, Stanford C, Tarnow D,
Wennerberg A. Osseointegration: On Continuing Synergies in Surgery,
Prosthodontics, and Biomaterial. Quintessence Publ Co. 2009.
17. Malterud K. Qualitative research, standards, challenges, and guidelines.
Lancet 2001; 358: 483-488.
18. Abrahamsson K.H, Wennstrm J.L, Hallberg U. Patients views on
periodontal disease; attitudes to oral health and expectancy of periodontal
treatment: a qualitative interview study. Oral Health & Preventive Dent
2008; 3:209-216.
19. Arnbjerg D, Sderfeldt B, Palmqvist S. Factors determing satisfaction with
dental care. Community Dent Health 1992; 3: 295-300.
20. Lahti S, Tuutti H, Hausen H, Krinen R. Patientsexpectations of an ideal
dentist and their views concerning the dentist they visited: do the views
conform to the expectations and what determines how well they conform?
Community Dent Oral Epi 1996; 6: 240-244.
21. Sondell K. Verbal communuication in prosthetic dentistry. Input-process-
outcome. Diss. 2001, Swed Dent J, suppl 146.
22. Graham R, Mihaylov S, Jepson N, Allen PF, Bond S. Determing need for
a Removable Partial Denture: a qualitative study of factors that influence
dentist provision and patient use. Brit Dent J 2006; 200: 155-158.
23. Bergendahl B. The relative importance of tooth loss and denture wearing in
Swedish adults. Community Dental Health 1989; 6: 106-111.
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Refusal of implant supported mandibular overdentures by elderly patients.
Gerodontology 2011; 28:62-68.
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49-59.
26. Hyland R, Ellis J, Thomason M, El-Fehy A, Moynihan P. A qualitative
study on patients perspectives of how conventional and implant-supported
dentures affect eating. J Dent; 37:718-723.
27. Hugoson A, Koch G, Gthberg C, Helkimo AN, Lundin SA, Norderyd
O, Sjodin B, Sondell K. Oral Health of individuals aged 3-80 years in
Jonkoping, Sweden during 30 years (1973-2003). II review of clinical and
radiographic findings. Swed Dent J. 2005; 29: 139-155.
28. Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures
in the United States in 2020. J Prosthet Dent. 2002; 87: 5-8.
Table 1
dental situation of the informants
Patients part of the cost differs because of individual prerequisites which influences the subsidized part from the National
Dental Insurance System in Sweden

Pat no; Number of impl.; Major complications: Year of implant Cost (1000 SEK;
age; Jaw-Upper/Lower Failed osseo- treatment approx. 7 SEK for
genus: integration, 1 USD): Total and
Male/ Bone-augmentation, patients part;
Female Fractured Subjective opinion of
Superstructure cost: Not important,
Hesitated,
Great Importance
1: 70; F 6 impl:U 2009 58 resp 24; Not
2: 84; M 6 impl:U 2009 72 resp 19; Not
3: 75; F 6 impl:U;5 impl:L Bo 2008 164 resp 27; Hes
4: 68; M 4 impl:U;3 impl:L F:1 impl 2008 108 resp 32; Not
5: 67; M 4 impl:U 2008 110 resp 28; Not
6: 64; F 5 impl:U F:3 impl 2008 46 resp 16; Not
7: 76; F 6 impl:U;5 impl:L 2009 132 resp 24; Not
8: 71; F 6 impl:U F:1 impl 2009 67 resp 24; Not
9: 61; M 2 impl:U;2 impl:L 2009 73 resp 33; Not
10: 54; F 4 impl:U Su 2009 85 resp 42; Imp
Table 2
A JOURNEY FROM SOCIAL STIGMA TO
EXHILARATION WITH TRUST AND CONFIDENCE
IN THE DENTIST AS CENTRAL PART

Becoming an unsecure person Decreasingly worsened oral health


Living in pain and anxiety
Becoming a determined person Desire for a better solution turn in demand
Having trust in the dentist
Going through with the treatment
Becoming the person I once was Being free from the prison of pain and social
stigma
Having feelings of gratitude
Being caught by a more realistic
perspective Being hit by the pale cast of thought
Appendices
Oralprotetiska kliniken
Tfn 018-611 63 80
E-post protetik.folktandvarden@lul.se

INFORMATION
om forskningsprojekt

Folktandvrden i Uppsala bedriver ett gemensamt forskningsprojekt, tillsammans med


Hgskolan i Malm, som syftar till att beskriva behov och efterfrgan av tandvrd och
d speciellt implantatbehandling.
Behov och efterfrgan av tandvrd har ndrats avsevrt under de senaste decennierna.
Nya behandlingsmetoder som implantatbehandling har blivit vanliga och pverkande
faktorer som bl.a. tandlkarens kunskaper har ndrats. Men ven mnga andra faktorer
inverkar p vilken behandling som vljs, som t.ex. instllning till vrd, kostnader och
vntetider.
Syftet med detta forskningsprojekt r att underska vad som fr patienter att vlja, eller
inte vlja, implantatbehandling vid avsaknad av tnder.

Du hr till de patienter som ftt behandling p Specialisttandvrden i Uppsala och vi har


ftt Ditt namn via klinikens patientregister. Du tillfrgas om du vill delta i studien.

Den planerade studien kommer att ske genom att en intervju genomfrs p en
verenskommen plats i Uppsala. Ngon klinisk underskning kommer inte att ske.
Intervjun kommer att ta cirka 45 min till 1 timme dr ljudinspelning sker. Detta sker fr
att undvika risken att inte hinna med att notera vad som sgs vid intervjun. Intervjun
kommer drefter att skrivas ut men i avidentifierad och kodad form.

Materialet frn Din intervju kommer att hanteras med sekretess och frvaras inlst utan
mjlighet att identifiera utan en kodnyckel som kommer att frvaras separat. Materialet
kommer inte att lmnas vidare till ngra externa uppdragsgivare och kommer att
behandlas s att inga obehriga kan ta del av dem. Ansvarig fr dina personuppgifter r
Malm Hgskola.
Hantering av intervjumaterialet kommer att ske enligt personuppgiftslagen (1998:204).

Sammanfattande resultat frn intervjuerna kommer att publiceras i vetenskaplig tidskrift


men utan ngon mjlighet till att identifiera ngon intervjuperson.
Om redovisning av statistik och forskningsresultat sker i andra sammanhang s kommer
det enbart att ske i avidentifierat skick.

Specialisttandvrden Kaniken
Oralprotetiska kliniken Vstra gatan 16 Box 1813 751 48 Uppsala tfn 018-611 63 80 fax 018-69 29 47

protetik.folktandvarden@lul.se pg 696764-0 org nr 232100-0024


2 (2)

Intervjun kan nr som helst avbrytas utan att ngot specifikt skl behver anges. Varje
intervjuperson kan bestmma sig fr att inte lngre delta i studien, vilket naturligtvis
kommer att respekteras. I s fall frstrs allt material frn denna intervju.
Vare sig Du deltar i studien eller ej, eller om Du vljer att avbryta intervjun, kommer
inte att p ngot stt pverka en eventuell framtida behandling p Specialisttandvrden.
Material frn ngon av intervjuerna r inte heller tillgngligt fr ngon p kliniken eller
inom Folktandvrden.

Ansvariga fr genomfrande av studien r Prof. Bjrn Sderfeldt, Avd fr


tandhlsovrd, Odontologiska fakulteten, Malm hgskola, samt vertandlkare Birger
Narby, Specialisttandvrden Kaniken, Folktandvrden, Uppsala. Den sistnmnde r
studiens kontaktperson.
Forskningshuvudman r Folktandvrden, Landstinget i Uppsala Ln.
Personuppgiftsombud vid Malm Hgskola kan ns p telefon 040-665 70 00. Enligt
personuppgiftslagen, PuL, har du rtt att gratis en gng per r f ta del av samtliga
uppgifter om dig som hanteras och vid behov f eventuella fel rttade.
Kontaktperson r Birger Narby Folktandvrden, Specialisttandvrden Kaniken, Box
1813, 751 48 Uppsala, tel. 018-611 63 80.

Tack p frhand fr Din medverkan. Om du har ngra frgor r du vlkommen att


kontakta mig per telefon eller e-post.

Birger Narby

vertandlkare

e-post: birger.narby lul.se

Tel 018-611 63 80

Jag r tacksam om du inom en vecka returnerar det bifogade


samtyckesformulret i det bifogade kuvertet. Om du samtycker till intervjun s
kommer jag att kontakta dig fr att bestmma tid och meddela plats fr intervjun.
Om du inte vill delta i studien s skriv det bredvid din namnteckning.
Med vnlig hlsning
Birger Narby
INTERVJUGUIDE
Tandlshet och att f implantat - patientens upplevelser

Du har relativt nyligen genomgtt en behandling p Specialisttandvrden inom


Folktandvrden i Uppsala och ftt en kkbensfrankrad bro. Skulle Du vilja bertta fr
mig om det?

Vad var det som gjorde att Du bestmde Dig fr att genomg den hr behandlingen
och skaffa en kkbensfrankrad bro?

Vad innebr det fr Dig att ha ftt en kkbensfrankrad bro? Vilka fr respektive
nackdelar upplever Du?

Hur har Din livskvalitet pverkats av den hr behandlingen?

Hur upplever du att Din munhlsa r nu efter behandlingen? Hur var Din munhlsa
innan behandlingen?
Underskning av instllningen till tandvrd och behovet av
tandersttningar i rebro ln

1. Kn Man
Kvinna

2. Fdelser: ______________

3. Boendeort: Stad
Mindre samhlle
Landsbygd

4. Yrke:
(ange s noggrant som mjligt, inte bara titel. Fr pensionr, ange tidigare yrke)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Arbetsgivare

___________________________________________________________________________

___________________________________________________________________________

Egen fretagare Ja Nej

5. Vilken utbildning har Du?

Folkskola/grundskola
Gymnasium
Hgskoleutbildning
Annan utbildning (Ange vilken)

___________________________________________________________________________

___________________________________________________________________________
6. Vilket civilstnd har Du?

Gift/sammanboende
Ensamstende
Ogift
Frnskild
nka/nkling

7. Din egen rsinkomst fre skatt fr nrvarande:

Ungefr _______________ kr

8. Ditt hushlls sammanlagda rsinkomst fre skatt fr nrvarnade:

Ungefr _______________ kr

9. Nr undersktes Du senast av tandlkare?


Fr mindre n 1 r sedan
Fr 1 3 r sedan
Fr 3 5 r sedan
Fr mer n 5 r sedan

10. r du njd med Dina tnder?


Ja
Nej
(Om du svarar Nej): Vad upplever Du som problem med Dina tnder?

________________________________________________________________

________________________________________________________________

________________________________________________________________

11. Kan Du tugga all sorts mat?


Mycket bra
Ganska bra
Mindre bra
Dligt
12. Nedan fljer ngra pstenden om tnder och tandvrd som vi vill att Du tar stllning till.
Ange Din instllning med ett kryss p linjen.

Instmmer Instmmer
absolut absolut
inte

a. Att ha vackre och perfekta tnder r


mycket viktigt fr hur man blir bemtt
av andra mnniskor. |__________________|_________________|

b. De spelar ingen roll hur man ser ut


i munnen, bara man kan tugga den mat
man tycker om. |__________________|_________________|

c. Mindre sknhetsfel p tnderna har


ingen betydelse, bara de fungerar. |__________________|_________________|

d. En tandlshet som syns r ngot


man br skmmas fr. |__________________|_________________|

e. Glappande lstnder kan se ljligt ut. . |__________________|_________________|

f. Tandlshet som syns frekommer nstan


bara hos socialt utslagna. |__________________|_________________|

g. Att ha lstnder r mycket besvrligt vid


kontakt med det motsatta knet. . |__________________|_________________|

13. Har Du alla Dina ursprunliga tnder i behll?

Ja G till frga 14
Nej G till nsta sida
Hr fljer ngra frgor om Dina tnder. I frgorna frekommer uttryck som behver
frklaras:
Ursprungliga tnder: Dina permanenta tnder, allts ej mjlktnder. Normalt 28-32
stycken. Hit rknas ocks de tnder som har lagningar, jacketkronor, stifttnder eller
liknande, dr ngon del av den ursprungliga tanden finns kvar.
Ersttning: Alla fastsittande eller avtagbara konstruktioner som helt erstter saknar
tnder, dvs dr ingen del av den saknade tanden finns kvar. Det kan vara bro/brygga,
implantat, delprotes eller helprotes.
Implantatbehandling: Som ersttning fr saknade tnder kan man numera i mnga
fall stta in s k implantat, skruvar av metallen titan som frankras i kkbenet. P dessa
kan man sedan stta konstgjorda tnder, som allts sitter fast.
Det mste finnas tillrckligt med ben i kken fr att fsta implantaten. I s fall gr
man tv operationer. Vid den frsta skruvas implantaten fast i kkbenet och fr lka in
under 3-6 mnader. En del av den tiden kan man inte ha ngot slags ersttning i
munnen, som tex protes. Vid den andra operationen stter man p en frlngning av
skruvarna. Efter 1-2 veckor kan sedan tandersttning fstas.
Implantatbehandling r inte srskilt smrtsamt och gen som regel mycket goda
resultat. Den r dock dyrbar. Patienten fr av egna pengar betala 12-15000 kr fr
implantatbehandling i en hel kke; det dubbla fr bda kkarna. En vanlig helprotes
fr bda kkarna kostar patienten totalt ca 2-3000 kr. Saknas en enstaka tand fr man
normalt betala ca 2-3000 kr fr implantatbehandling, ungefr lika mycket som fr en
vanlig bro/brygga. Dessa siffror anger patientavgiften. Frskringskassan och
landstinget str fr resten, som r den strre delen av kostnaden.

13. forts. (Om Du svarar Nej p fregende sida): Ange vilket eller vilka alternativ nedan
som gller fr Dig, separat fr ver- och underkke. G sedan till frga nr 17.

verkke Underkke
a. Jag saknar ngon enstaka tand (ej
visdomstand) och har ingen ersttning fr den
b. Jag saknar flera tnder (ej visdomstnder och
har inga ersttningar fr dem
c. Jag saknar alla tnder i angiven kke och har
inga ersttningar fr dem
d. Jag har fast ersttning (bro/brygga)
e. Jag har implantat (kkbensfrankrad bro)
f. Jag har avtagbar delprotes
g. Jag har helprotes
14. (Denna frga besvaras endast av Dig som har de ursprungliga tnderna i behll)

Om Du skulle frlora ngon eller ngra tnder, vilken typ av behandling skulle Du fredra?
Ange endast ett av nedanstende alternativ.

Fast bro/brygga
Avtagbar protes
Implantat
Ingen behandling
15. (Denna frga besvaras endast av Dig som har de ursprungliga tnderna i behll)

Om Du skulle frlora alla tnder i ngon kke, vilken typ av behandling skulle Du fredra?
Ange endast ett av nedanstende alternativ fr varje kke.

verkke Underkke
Fast bro/brygga (kan inte gras)
Implantat
Avtagbar protes
Ingen behandling

16. (Denna frga besvaras endast av Dig som har de ursprungliga tnderna i behll. G sedan
till frga 22!)

Om Du inte vill ha implantatbehandling, vilket eller vilka av fljande alternativ stmmer bst
in p Dig?

Ondigt att gra ngot t tandfrlusten


Implantat r ett fr stort ingrepp i kroppen
Implantat fr dyrt
Jag r rdd fr operationerna
Jag r rdd fr oknda biverkningar av implantat
Det rcker bra med vanliga lstnder
Annat
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

17. (Denna frga besvras endast av Dig som saknar en eller flera tnder och inte har
ersttning fr dem. Har Du ngon form av ersttning, g i stllet till frga 20)

Varfr har Du ingen ersttning fr Din tandfrlust? Ange ett eller flera av nedanstende
alternativ.

Har inte velat ha ngon ersttning


Behandling fr kostsam
Har frskt bra lstnder, men har inte fungerat
Har avrtts av tandlkare
Jag r rdd fr tandbehandling
Annat
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

18. (Denna frga besvras endast av Dig som saknar en eller flera tnder och inte har
ersttning fr dem. Har Du ngon form av ersttning, g i stllet till frga 20)

Vill Du ha implantatbehandling fr Din tandfrlust, om sdan behandling r mjlig?

Ja G till frga 22
Nej G till frga 19

19. Denna frga besvras endast av Dig som saknar en eller flera tnder och inte har
ersttning fr dem. Har Du ngon form av ersttning, g i stllet till frga 20)

Om Du inte vill ha implantatbehandling, vilket eller vilka av fljande alternativ stmmer bst
in p Dig?

Ondigt att gra ngot t tandfrlusten


Implantat r ett fr stort ingrepp i kroppen
Implantat fr dyrt
Jag r rdd fr operationerna
Jag r rdd fr oknda biverkningar av implantat
Det rcker bra med vanliga lstnder
Annat
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

20. (Denna frga besvaras endast av Dig som saknar en eller flera tnder och redan har ngon
ersttning fr dem. vriga, g till frga 22)

Skulle Du vilja ha implantat i stllet fr den ersttning Du redan har?

Ja G till frga 22
Nej G till frga 21
21. (Denna frga besvaras endast av Dig som saknar en eller flera tnder och redan har ngon
ersttning fr dem. vriga, g till frga 22)

Om Du inte vill ha implantatbehandling, vilket eller vilka av fljande alternativ stmmer bst
in p Dig?

Implantat r ett fr stort ingrepp i kroppen


Implantat fr dyrt
Jag r rdd fr operationerna
Jag r rdd fr oknda biverkningar av implantat
Den ersttning jag har fungerar bra
Annat
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Avslutningsvis vill vi stlla ngra allmnna frgor om den tandvrd


Du har erhllit tidigare.

22. (Denna och fljande frgor besvaras av alla)

r Du allmnt njd eller missnjd med den tandvrd Du har erhllit tidigare?
Mycket njd
I stort sett njd
Ganska missnjd
Mycket missnjd

23. Har Du i huvudvrk ftt tandvrd hos privattandlkare eller hos folktandvrden?

Privattandvrd
Folktandvrd

24. Har Du i allmnhet haft mjlighet att beska den tandlkare Du nskat f behandling av?
Alltid
Ofta
Ibland
Sllan
Aldrig
25. Hr fljer ngra frgor om Din allmnna instllning till tandvrd. Ange Din instllning
med ett kryss p linjen.

Instmmer Instmmer
absolut absolut
inte

a. Alla borde ha helt gratis tandvrd |__________________|_________________|

b. All tandvrd borde drivas av landsting |__________________|_________________|

c. Tandvrd br betalas p samma stt som


annan sjukvrd. |__________________|_________________|

d. Tandvrdsfrskringen r bra som den r |__________________|_________________|

e. Det r viktigare att resurser satsas p hjrt-


byten n p tandvrd |__________________|_________________|

f. Samhllet borde inte betala ngot fr sdan


tandvrd som grs fr utseendet skull |__________________|_________________|

Tack fr din medverkan!


LUNDS
UNIVERSITET

UNDERSKNING AV INSTLLNINGEN TILL


TANDVRD OCH TANDERSTTNINGAR
Inom tandvrden har mnga nya metoder utvecklats under senare r.
En sdan ny teknik r insttning av implantat i stllet fr tnder som
frlorats. Denna metod innebr att man i mnga fall kan f en fast
ersttning i stllet fr avtagbar protes. "Lstnder" kan allts
undvikas. Behandling med implantat ar dock mycket kostsam bde fr
patient och samhlle.
Fr snart tio r sedan fick Du ett frgeformulr som bl.a. handlade
om Din instllning till implantatbehandling. Resultaten frn denna
frsta underskning har uppmrksammats mycket, och vi tror den
information vi kunnat frmedla har haft stor betydelse fr kunskapen
om implantat och utvecklingen av tandvrden. Nu vill vi gra en
uppfljning av den frra underskningen.
Vad anser Du nu, hur har det gtt med Dina lnder och de
ersttningar Du eventuellt haft eller har? Det r viktigt fr oss med
kunskap om frgor som dessa, srskilt nu nr tandvrdsfrskringen r
under frndring.
Du blev frra gngen slumpmssigt utvald att ing i
underskningen. Nu vill vi be Dig att s snart som mjligt fylla i
formulret och snda tillbaka det i bifogat portofritt svarskuvert.
Deltagande i underskningen r givetvis helt frivilligt. Det r dock
viktigt f r mjligheterna att dra slutsatser frn
underskningen att s mnga som mjligt besvarar enkten.
De svar som lmnas skyddas av Sekretesslagen (Sekretesslagen 9 kap
4 och sekretessfrordningen 3 ). Bearbetningen av underskningen
kommer att ske p sdant stt att uppgifterna i dataregistren och
resultaten i redovisningen inte kan kopplas till ngon enskild individ.
Ditt namn och adress har vi ftt frn befolkningsregistret.
Om Du har frgor eller synpunkter p underskningen kan Du ringa
oss eller tandskterska Solveig Nsstrm-Nilsson, tel 040-322123, kl
8-16 mndag till fredag.

Vi tackar p frhand fr Din medverkan

Sigvard Palmqvist Bjrn Sderfeldt


Professor Professor
tel:00945-35326745 040-322218
Frst kommer ngra frgor om Din tandvrd och hur Du upplever
Dina tnder.

1. Nr undersktes Du senast av tandlkare? Fr minde n 1 r sedan


Fr 1 3 r sedan
Fr 3 5 r sedan
Fr mer n 5 r sedan
Har ej underskts

Minns ej

2. Nr undersktes Du senast av tandhygienist Fr minde n 1 r sedan


eller profylaxtandskterska? Fr 1 3 r sedan
Fr 3 5 r sedan
Fr mer n 5 r sedan
Har ej underskts av ngon av dessa

Minns ej

3. Var har Du de senaste fem ren huvudsakligen Privattandvrd


ftt tandvrd? Folktandvrd
Bde privat- och folktandvrd

Ej ftt tandvrd

4. Ungefr hur ofta gr Du till tandvrd? Tv eller fler gnger/r


En gng/r
Vartannat r
Mer sllan

5. Ungefr hur mycket har Du sjlv betalat Inget alls


fr Din tandvrd de senaste tolv mnaderna? Mindre n 300 kr
300 1000 kr
1001 2000 kr
2001 5000 kr
Mer n 5000 kr

6. r Du allmnt njd eller missnjd med den Mycket njd


Tandvrd Du har erhllit tidigare? I stort sett njd
Mindre njd
Ganska missnjd
Mycket missnjd
7. Har Du ngon gng under de senaste fem Ja, flera gnger
ren bytt eller velat byta tandlkare drfr Ja, ngon enstaka gng
att Du varit missnjd? Nej

Minns ej

8. r Du allmnt njd med Dina tnder? Ja, mycket njd


Ja, ganska njd
Nej, inte srskild njd
Nej, inte alls njd

9. Kan Du tugga all sorts mat, t ex ntter eller Mycket bra


pplen? Ganska bra
Mindre bra
Dligt

10. Om Du har tandersttning i form av fast bro/ Ja, mycket njd


brygga eller avtagbar protes, r Du allmnt njd Ja, ganska njd
eller missnjd med den? Nej, inte srskilt njd
Nej, inte njd alls
Har ej sdan tandersttning

11. Upplever Du allmnt Dina tnder som Mycket bttre


bttre eller smre n Dina jmnrigas? Ngot bttre
Varken bttre eller smre
Mycket smre

12. Har Du under de senaste tolv mnaderna Ja, flera gnger


ngon gng varit sjukskriven p grund av problem Ja, ngon enstaka gng
med Din mun eller Dina tnder? Nej

Minns inte
12 a. Om ja, ungefr hur mnga dagar? __________________ dagar
13. Man kan ha olika instllningar till tnder och deras utseende och stt att fungera. Nedan
fljer ngra pstenden som vi ber att Du tar stllning till.
Instmmer Instmmer
Ange Din instllning absolut absolut
med ett kryss p linjen. inte

a. Att ha vackre och perfekta tnder r


mycket viktigt fr hur man blir bemtt
av andra mnniskor. |__________________|_________________|

b. De spelar ingen roll hur man ser ut


i munnen, bara man kan tugga den mat
man tycker om. |__________________|_________________|

c. Mindre sknhetsfel p tnderna har


ingen betydelse, bara de fungerar. |__________________|_________________|

d. En tandlshet som syns r ngot


man br skmmas fr. |__________________|_________________|

14. Man kan ha mnga olika besvr frn munnen och tnderna.
Upplever Du fr Din del att Du har ngot eller ngra av nedanstende besvr eller
Bekymmer? Tnk igenom och besvara varje exempel.

Ganska
Inga Vissa mycket Stora
besvr besvr besvr besvr
Tndernas frg
Tndernas form
Sneda tnder
ver- eller underbett
Fr glest mellan tnderna
Fr trngt mellan tnderna
Sveda i munnen
Sr eller blsor i munnen
Smrta runt kklederna
Knppningar/knaster frn kklederna
Svrigheter att gapa stort
Tandgnissling/pressning
Bldning frn tandkttet
Dlig andedrkt
Tandvrd
Ilningar i tnderna
15. Hur ser det ut i Din mun? Ange vilket eller vilka alternativ som gller fr Dig, bde fr
ver- och underkke. Tnk p att flera olika alternativ r mjliga. Har Du tex bde en
tandlucka och en bro i en kke kryssar Du i bde b och e fr den kken. Har Du bde en
fast ersttning och en avtagbar delprotes i samma kke kryssar Du fr alternativen e och
g fr den kken. Har Du implantat, f, kan Du ocks ha en fast ersttning, e, eller en
avtagbar helprotes, h.
verkke Underkke
a. Jag har alla ursprungliga tnder i behll
(visdomstnder rknas inte)
b. Jag saknar ngon enstaka tand (ej
visdomstand) och har ingen ersttning fr den
c. Jag saknar flera tnder (ej visdomstnder och
har inga ersttningar fr dem
d. Jag saknar alla tnder i angiven kke och har
inga ersttningar fr dem
e. Jag har fast ersttning (bro/brygga)
f. Jag har implantat
g. Jag har avtagbar delprotes
h. Jag har avtagbar helprotes

16. Du som helt eller delvis saknar tnder i ngon kke, vill Du allmnt ha
implantatbehandling om det tekniskt mjligt?
verkke Underkke
Ja, absolut
Ja, troligen
Varken ja eller nej
Nej, troligen inte
Nej, absolut inte
Saknar inte tnder

17. Du som delvis saknar egna tnder och idag har en avtagbar delprotes, skulle Du istllet
vilja ha behandling med implantat, om det r mjligt?
verkke Underkke
Ja
Nej
Osker
Har ej avtagbar delprotes
18. Du som helt saknar egna tnder i ngon eller bda kkarna och idag har en avtagbar
helprotes, eller saknar ersttning, skulle Du vilja ha behandling med implantat, om det r
mjligt?
verkke Underkke
Ja
Nej
Osker
r ej helt tandls i denna kke

19. Om Du saknar en eller flera tnder och inte har ersttning fr dem, varfr har Du inte ltit
erstta dem? Flera olika alternativ kan anges.

Har inte velat ha ngon ersttning


Behandling fr kostsam
Har frskt bra lstnder, men det har inte fungerat
Har avrtts av tandlkare
Har avsttt p grund av rdsla fr tandbehandling
Saknar inte tnder utan att de r ersatta

20. Om Du som har egna tnder skulle frlora ngon eller ngra tnder, vilken typ av
behandling skulle Du fredra? Ange endast ett alternativ fr varje kke.

verkke Underkke
Fast bro/brygga p egna tnder
Avtagbar protes
Krona/bro p implantat
Ingen behandling
r redan helt tandls i denna kke

21. Om Du som har egna tnder skulle frlora alla tnder i ngon kke, vilken typ av
behandling skulle Du fredra? Ange endast ett alternativ fr varje kke.

verkke Underkke
Avtagbar protes, lstnder
Fast bro/brygga p implantat
Avtagbar protes p implantat
Ingen behandling
Nej, absolut inte
r redan helt tandls i denna kke
22. Om Du inte kan tnka Dig implantatbehandling, vilket eller vilka alternativ stmmer
bst in p Dig? Flera alternativ kan anges.

Ondig att gra ngot t tandfrlusten


Implantat r ett fr stort ingrepp i kroppen
Implantat r fr dyrt
Jag r rdd fr operationerna
Jag r rdd fr oknda biverkningar av implantat
Behver ingen ersttning
Vill ha implantat
Annat skl
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

23. Sedan den frra underskning, har ngon eller ngra av fljande hndelser intrffat fr
Dig? Flera alternativ kan anges.

Har frlorat en enstaka tand.


Har frlorat ngra tnder
Har frlorat de flesta tnderna i ngon kke
Har frlorat alla tnder i ngon kke
Bro/brygga har gtt snder
Ftt ny bro/brygga
Ftt ny avtagbar delprotes
Ftt helprotes
Ftt implantat
Implantat har lossnat
Haft ordentlig infektion/inflammation i munnen
Annat
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
24. Man kan ha olika uppfattningar om hur viktigt tandvrd r och hur mycket samhllet br
ansvara fr. Nedan fljer ngra pstenden som vi ber att Du tar stllning till. Ange Din
instllning med ett kryss p linjen.
Instmmer Instmmer
absolut absolut
inte

a. Alla borde ha helt gratis tandvrd |__________________|_________________|

b. All tandvrd borde drivas av stat, landsting


eller kommun |__________________|_________________|

c. Tandvrd br betalas p samma stt som


annan sjukvrd. |__________________|_________________|

d. Tandvrdsfrskringen br ocks tcka


ersttningar av frlorade tnder |__________________|_________________|

e. Det r viktigt att f ersttning fr stora


och kostsamma tandbehandlingar n fr
rutintandvrd |__________________|_________________|

f. Samhllet br inte betala ngot fr sdan


tandvrd som grs fr utseendet skull |__________________|_________________|

Till sist kommer ngra frgor om Dig sjlv, fr att vi skall frst bakgrunden
till olika uppfattningar om tnder och tandvrd.

25. Din boendeort:

Storstad
Storstadsfrort
Medelstor stad
Mindre stad/samhlle
Landsbygd

26. Vilken av fljande yrkeskategorier passar bst in p Ditt huvudsakliga yrke? (Fr
pensionr, studerande eller arbetsls, ange tidigare yrke)

Ej facklrd arbetare i industri eller tjnst


Facklrd arbetare i industri eller tjnst
Lgre tjnsteman
Tjnsteman p mellanniv
Hgre tjnsteman eller fri yrkesutvare
Egen fretagare
27. Vilken r Din huvudsakliga sysselsttning?

Arbetar heltid
Arbetar deltid
I arbetsmarknadspolitisk tgrd
Arbetsls
Hemarbetande
Studerande eller annat

28. Vilken eller vilka utbildningar har Du? (Flera svarsalternativ r mjliga)

Folkskola/grundskola
Realskola
Folkhgskola, 2-rigt gymnasium
3- eller 4-rigt gymnasium
Hgskoleutbildning
Anna utbildning (Ange vilken)
________________________________________________________________

________________________________________________________________

29. Vilket civilstnd har Du?

Gift/sammanboende
Ogift/ensamboende

30. Ungefr vilken rsinkomst fre skatt har Du fr nrvarande?

Mindre n 100000 kr 251 300000 kr


101 - 150000 kr 301 350000 kr
151 200000 kr 351 400000 kr
201 - 250000 kr Mer n 400000 kr

Tack fr din medverkan!


demand For proStethic

on impl ant dentiStry


dentiStry treatment
Swedish Dental Journal, Supplement 218, 2011

with Special FocuS


FactorS Shaping
Birger narBy

S w e d i S h d e n t a l j o u r n a l , S u p p l e m e n t 2 1 8 , 2 0 11 . d o c t o r a l d i S S e r t a t i o n i n o d o n t o l o g y
B i r g e r n a r By Fac t o r S S h a p i n g d e m a n d F o r p r o S t e t h i c d e n t i S t ry t r e at m e n t w i t h S p e c i a l F o c u S o n i m p l a n t d e n t i S t ry m a l m u n i V e r S i t y 2 011

malm uniVerSity
205 06 malm, Sweden
www.mah.Se
isbn/issn 978-91-7104-415-0 / 0348-6672