Giédre Berretin-Felix A longitudinal study of quality of life of

Hugo Nary Filho

Carlos Roberto Padovani
elderly with mandibular implant-
Wellington Monteiro supported fixed prostheses
Machado

Authors’ affiliations:
Giédre Berretin-Felix, Department of Speech
Pathology and Audiology, University of São Paulo –
Bauru, São Paulo, Brazil
Hugo Nary Filho, Dental School, University of
Sagrado Coração – Bauru, São Paulo, Brazil
Carlos Roberto Padovani, Biosciences Institute,
Medical School, São Paulo State University –
Botucatu, São Paulo, Brazil
Wellington Monteiro Machado, Department of
Internal Medicine, São Paulo State University,
Botucatu, São Paulo, Brazil
Correspondence to:
Giédre Berretin-Felix
Speech Pathology/Audiology Department, Bauru
Dental School, USP
Al. Dr. Octávio Pinheiro Brisolla, 9-75, C.P. 73
CEP 17012-901 – Bauru, São Paulo, Brazil.
Tel.: þ 55 (14) 3235-8332
Fax: þ 55 (14) 3223-4679
e-mail: gfelix@usp.br
Key words: complete denture, implant-supported prosthesis, oral health in elderly, quality
of life in elderly
Abstract
Objectives: To verify the consequences of implant-supported fixed oral rehabilitation on
the quality of life (QL) of elderly individuals.
Material and methods: Fifteen patients were studied, being 10 females and five males; all
were aged 460 years, were completely edentulous, wore removable dentures on both
arches, and were treated with implant-supported fixed dentures. Three QL questionnaires
were applied, two related to the oral conditions (Oral Impact on Daily Performance –
OIDP – and Oral Health Impact Profile, short version – OHIP-14) and one dealing with global
aspects (World Health Organization Quality of Life – WHOQOL-BREF), before 3, 6, and 18
months after surgical placement of implants.
Results: Scores in the OIDP and OHIP-14 questionnaires were better after dental treatment.
The WHOQOL-BREF was less sensitive, confirming the higher reliability of specific
questionnaires (focal) compared with general questions in such situations.
Conclusion: Treatment with implant-supported fixed prostheses improved QL in the
elderly; these effects are better detected by specific instruments focused on the subject.

Orofacial alterations, including diseases McMillan 2003), resulting in few restric-

Date:
Accepted 23 January 2007
To cite this article:
Berretin-Felix G, Nary Filho H, Padovani CR, Machado
WM. A longitudinal study of quality of life of elderly
with mandibular implant-supported fixed prostheses.
Clin. Oral Impl. Res. 19, 2008; 704–708
doi: 10.1111/j.1600-0501.2007.01451.x
and pain, have considerable repercussion
on aspects of personal and social life and
can affect daily activities (Gift & Redford
1992). In the elderly, tooth loss may also
have important adverse effects on different
aspects of quality of life (QL), particularly
in institutionalized individuals (Sheiham
et al. 2001).
To counteract dental loss, treatment
consists of placing removable or fixed den-
tures. These restore the vital functions of
mastication and swallowing of foods. In
addition, esthetics, impaired by the pre-
sence of non-restored spaces or inadequate
dentures, is improved. Oral rehabilitation
by placement of conventional or implant-
supported dentures has positively effected
QL (Allen et al. 2001, 2006; Allen &
tions on social activities or psychological
problems (Bouma et al. 1997). Also, with
respect to chewing (Grandmont et al.
1994), comfort, functionality, speech, es-
thetics, self image, and oral health (Cibirka
et al. 1997), implant-supported fixed den-
tures seem to provide greater benefit than
removable dentures, with a better impact
on daily activities (Melas et al. 2001).
Specifically in cases of implant-supported
dentures, long-term post-operative evalua-
tion of two implants with ball attachments
shows better results than triple-bar with
respect to phonetics, esthetics, and social
function (Timmerman et al. 2004).
Wen looking at functional aspects
and oral health specifically in the elderly,
implant-supported rehabilitation provides

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 Berretin-Felix et al . Quality of life of elderly with implant-supported prostheses

better results than conventional oral health

treatment (Heydecke et al. 2003) and
improvement in oral function and QL
parameters (Awad et al. 2003).
Selection of the instrument for evaluating
QL in dental patients could have a powerful
influence on the final results, as instru-
ments specifically designed for problems
related to the oral cavity such as OHIP are
apparently more sensitive than generic in-
struments such as SF36 in detecting exist-
ing conditions (Allen et al. 1999; Allen &
Fig. 1. Radiographic image demonstrating adequate mandibular bone structure for implant surgery.
McMillan 2003; Heydecke et al. 2003).
Most studies on the QL impact of the
different types of available dentures use a
heterogonous methodology and non-speci-
fic age groups. The objective of this study
was to evaluate the effects of implant-sup-
ported fixed oral rehabilitation on QL in a
homogenous age group consisting of eden-
tulous elderly individuals, who make up an
especially relevant group due to the higher
incidence of dental problems and damage to
oropharyngeal neuromuscular function,
both of which potentially reduce the QL.

Materials and methods Fig. 2. Occlusal view of conventional implant distribution using a surgical guide.

Patients Drilling and conventional implant place- Abutments or intermediate IOL-type

Fifteen elderly individuals were selected for
this study, being 10 females and five
males, aged 60–76 years (mean 66 years).
All enjoyed good general health, were com-
pletely edentulous, wore complete remo-
vable dentures with the maxillary arch in
good clinical condition, and had adequate
mandibular bone structure for placement of
implants with minimum size of 10 mm
(Fig. 1).
This study was revised and approved by
the Institutional Review Board of Univer-
sity of Sagrado Coração on March 12,
2003, under protocol no. 001/2003.
Surgical-prosthetic procedures
Before surgery, the occlusal relationship
and vertical dimension were reestablished
by replacement of mandibular dentures and
all inadequate maxillary dentures. The
mandible protocol immediate load rehabi-
litation system was based on fixing five
osseointegrated implants Osseotite (3i Im-
s
plant Innovations , Palm Beach Gardens,
FL, USA), with simultaneous placement of
the prosthetic abutments and provisional
prostheses, in a surgical time of up to 8 h.
ment was performed with the aid of a pre-
viously fabricated surgical guide for
achievement of proper implant distribution,
with maximum distal extension to mini-
mize the cantilever effect (Fig. 2). In all
regions, final drilling was standardized with
3-mm diameter bur and tapping, despite
differences in bone quality between patients.
This was compensated for by selection of
implant diameter, namely 3.75 or 4 mm.
Self-threading implants (3i NT Osseo-
tite) with 3.75- and 4-mm diameters and
adjustable length were employed. Implant
leveling was based on the height of the
surrounding bone crest, leaving the hexa-
gonal platform of the implant head at or
slightly below the crest level, allowing
total covering of threads.
After placement, initial stability was
measured by analysis of resonance fre-
quency, to verify the efficacy of this reha-
bilitation system. Immediate load was
indicated when there was insertion
torque above 32 N and stability torque
above 60 N (assessed by Osstel, resonance
s
frequency, Osstell -Integration Diagnos-
tics, Göteborg, Sweden).
s
prostheses (3i implant Innovations ) were
inserted to complement the surgical treat-
ment. Height selection was based on the
thickness of the overlying mucosa and
implant bone depth, aiming to maintain
the connection edge supragingivally. This
was followed by application of torque from
the screw at 20 N/cm2 for perfect seating
on the implant head. The surgical wound
was then cleaned and simple interrupted
suture of the flap was performed with
polyglactin 910 suture 4.0 (Vicryl).
At the beginning of the prosthetic work,
IOL gold cylinders for application of acrylic
on provisional prostheses were screwed on
the abutments with gold screws. These
cylinders have retentions and a base area
that allow placement of a rubber dam. The
previously perforated rubber dam was
adapted so as to allow application of acrylic
resin, in the plastic stage, to capture the
cylinders without invading the surgical
area. This was performed using the
patient’s own mandibular denture, pre-
viously ground on its internal aspect, to
allow positioning of IOL system cylinders
and distal extension bars for greater resis-

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Berretin-Felix et al . Quality of life of elderly with implant-supported prostheses

tance against posterior cantilever. The den-

ture was then sent to the dental technician
for final acrylic application, finishing and
burnishing, allowing for posterior screwing.
After placement, occlusal adjustments
were performed and the screw orifices
were restored. Figure 3 shows the final
condition of mandibular rehabilitation.
After treatment completion, antibiotics
and analgesics were prescribed to all pa-
tients, who also received information on
oral hygiene, diet, and application of ice on
the surgical area for the first 48 h post- Fig. 3. Final condition of mandibular implant-supported fixed prosthesis.
operatively, followed by application of
moist heat on subsequent days. Table 1. Median and semi-amplitude totals of global quality of life scores obtained from
applying OHIP-14 and OIDP, before (Pre), and 3 (Post1), 6 (Post2), and 18 (Post3) months
after dental treatment
QL evaluation Questionnaire Period Statistical
QL was evaluated before, and 3 (Post1), 6 results
Pre Post1 Post2 Post3
(Post2), and 18 (Post3) months after surgi-
cal prosthetics. Three different question- OHIP-14 18  20c 6  10.5b 0  4a 3  15a Po0.001
OIDP 20  48b 0  18.5a 0  2.5a 0  17.25a Po0.001
naires were used: two specific and one
generic. Patients were given prior instruc- Different letters indicate statistical differences between periods.
tions and detailed advice on the different OHIP-14, Oral Health Impact Profile – short form; OIDP, Oral Impact on Daily Performance.

aspects and questions contained in the

questionnaires, which should ideally be
filled in privately in their own homes.
This did not occur in four cases because
the patients reported difficulties in under-
standing the text or pleading poor sight,
consequently obliging the author to help
them filling in the questionnaires. In these
circumstances, extra care was taken with
regard to minimizing external interference
on the accuracy of replies.
The three questionnaires measuring QL
were: Oral Health Impact Profile – short
form (OHIP-14), Oral Impact on Daily
Performance (OIDP), and the abbreviated
version of the World Health Organization
Quality of Life (WHOQOL-BREF).
OHIP-14 was the translated version by
Oliveira & Nadanovsky (2005) from the
simplified OHIP. This instrument consists
of seven categories with two questions
each, to which values are assigned; when
added together, they result in a global
score. For each of the seven categories,
the mean value is calculated from the
values attributed to the two related ques-
tions.
The version of OIDP used in our study
was based on the translation by Goes
(2001). It is composed of a list of eight
items with questions on the possible diffi-
culties presented by individuals. Quantifi-
cation of their impact measured by this
instrument is based on frequency and se-
verity variables scored over a seven-point
scale. The result for each item was ob-
tained by adding the actual scores, besides
calculation of a general score from the
formula suggested by Sheiham (2000).
Scores obtained covering the 3 months
before application of the OHIP-14 and
OIDP instruments were used as standard
reference values for the questionnaires.
The WHOQOL-BREF was a translation
into Portuguese adapted by the Psychiatry
and Legal Medicine Department of Federal
University of Rio Grande do Sul (Fleck
et al. 2000). It consists of 26 questions
about the 2 weeks preceding initial applica-
tion of the questionnaire and records infor-
mation on QL considering four areas:
physical, psychological, social relations,
and environment. The scores are calculated
using a specific software developed by the
Biostatistics Department of Botucatu Med-
ical School – UNESP.
Statistical analysis
Score variables were analyzed by the Fried-
man test followed by the Student–New-
man–Keuls test. Comparisons between
QL results from the WHOQOL-BREF in-
strument were analyzed by the paired
t-test followed by Wilcoxon sign test. A
significance level of 5% was adopted in all
tests.
Results
Table 1 shows the results of the global QL
scores from the OHIP-14 and OIDP proto-
cols for the individuals studied. Higher
scores show worse results. Statistical ana-
lysis demonstrated that oral rehabilitation
using fixed implant-supported dentures on
the mandibular arch had a positive impact
on the elderly individuals’ perception of
their QL. Results from both OHIP-14
and OIDP showed a positive repercussion
in QL, even from the first evaluation (3
months after surgery) and continuing until
the last measurement after 18 months.
Tables 2 and 3 show scores correspond-
ing to each component category of the two
instruments. Table 2 shows that the scores
before dental treatment (Pre) were signifi-
cantly higher or rather worse than those 6
and 18 months after surgery, except for the
functional limitation category. Significant
differences between the first and second
evaluations were found for the categories of
physical and psychological limitation; this
was not observed for functional and social
limitation and incapacity.
In Table 3, statistical analysis of results
from the OIDP categories showed that
scores obtained before dental treatment
were higher than those for 3, 6, and 18
months after treatment for the categories of

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 Berretin-Felix et al . Quality of life of elderly with implant-supported prostheses

Table 2. Median and semi-amplitude totals of quality of life scores from each category of dressed in the first two protocols, but
OHIP-14, before (Pre), and 3 (Post1), 6 (Post2), and 18 (Post3) months after dental treatment equally about an individual’s systemic
Category Period Statistical
well-being, which was assessed by the
results
Pre Post1 Post2 Post3 WHOQOL-BREF protocol. The OHIP-14
Functional limitation 1  2b 0  0.75ab 0  0.5a 0  0.75ab Po0.005 protocol was applied because of its exten-
Physical pain 2  1.5b 1  1a 0  0.5a 0  1a Po0.001 sive international success in evaluating the
Psychological discomfort 2  2b 0.5  1a 0  0.5a 0  2a Po0.001
impact of dental treatment on QL (Allen
Physical limitation 2  1.75b 0  1.25a 0  0.5a 0  1.25a Po0.005
Psychological limitation 1  2c 0.5  1b 0  0.5a 0  1a Po0.001 et al. 2001; Allen & McMillan 2003;
Social limitation 0  1b 0  0.5ab 0  0a 0  1.25a Po0.05 Heydecke et al. 2003). The OIDP
Incapacity 0  1.25b 0  0.5ab 0  0a 0  1.25a Po0.05 questionnaire had already been applied
Different letters indicate statistical differences between periods. to geriatric populations in different
OHIP-14, Oral Health Impact Profile – short form. studies in Europe (Tsakos et al. 2001,
2004) and Asia (Srisilapanan & Sheiham
2001), and was used in a work published
Table 3. Median and semi-amplitude totals of quality of life scores from each category of by Melas et al. (2001) on cases of rehabili-
OIDP, before (Pre), and 3 (Post1), 6 (Post2), and 18 (Post3) months after dental treatment tation with implant-supported prostheses.
Category Period Statistical
It has also been used in our country
results
Pre Post1 Post2 Post3 in studies on orthodontic treatment
Eating 20  12.5b 0  10a 0  5a 0  12.5a Po0.05 (Oliveira & Sheiham 2003, 2004) and to
Speaking 5  12.5b 0  10a 0  3a 0  12.5a Po0.001 assess the impact of toothache on the QL
Cleaning 0  12.5 0  6 0  0 0  10 P40.05
during pregnancy (Oliveira & Nadanovsky
Sleeping 0  12.5b 0  6a 0  0a 0  0a Po0.05
Maintenance of emotional status 0  12.5 0  10 0  0 0  0 P40.05 2005).
Performing tasks 0  12.5 0  5 0  0 0  0 P40.05 Results from the OHIP-14 show that
Being with others 0  12.5b 0  5a 0  0a 0  0a Po0.05 placement of implant-supported fixed den-
Performing physical activities 0  12.5 0  0 0  0 0  5 P40.05
tures can cause improvements in patients’
Different letters indicate statistical differences between periods. QL; this is in agreement with Allen et al.
OIDP, Oral Impact on Daily Performance. (2001) and Allen & McMillan (2003).
Similar findings were presented by Awad
Table 4. Median and inter-quartile semi-amplitude scores from the different dominions of et al. (2003), Heydecke et al. (2003), and
quality of life obtained by applying WHOQOL-BREF, before (Pre), and 3 (Post1), 6 (Post2), Att & Stappert (2003), who investigated
and 18 (Post3) months after dental treatment
Aspects Periods Statistical
groups of elderly individuals. It is im-
results portant to stress that our study found
Pre Post1 Post2 Post3
statistically significant benefits in most
Physical 71.43  11.16 64.29  13.36 60.71  8.06 71.43  12.05 P40.05 tested categories, which were intensified
Psychological 75  6.25 62.5  5.73 58.33  10.46 70.83  13.54 P40.05
Social relations 66.67  15.59 75  12.5 75  16.53 75  15.63 P40.05
throughout the experimental period,
Environmental 62.5  7.42 62.5  8.59 62.5  3.16 62.5  7.42 P40.05 revealing a tendency of increasing recovery
over time.
WHOQOL-BREF, World Health Organization Quality of Life.
When the OIDP instrument was used,
it reported that there were already
eating, speaking, being with other people, Discussion equal improvements in QL related to
and sleeping, showing a sustained improve- eating, speaking, sleeping, and being
ment of these QL aspects throughout the Concern with the impact of dental treat- with other people at 3 months after treat-
postsurgical period. However, the other ment on an individual’s QL is becoming ment, which were maintained at 6 and 18
categories analyzed, namely oral cavity increasingly common. It is particularly months. Also, no changes were seen
cleaning, maintenance of emotional status, interesting to evaluate QL consequences from the treatment in relation to teeth
and performing tasks and physical activ- in the elderly population, commonly and oral cavity cleaning, maintenance
ities did not show significant differences subjected to different models of oral reha- of emotional status, and performing
between different evaluation periods. bilitation. daily tasks and physical activities. Melas
Table 4 shows the QL results from the In our study, QL before and after treat- et al. (2001) found more favorable
WHOQOL-BREF questionnaire. In this ment was compared in elderly patients QL effects from implants than conven-
case, higher scores indicate better QL. submitted to surgical placement of im- tional dentures in edentulous individuals
Statistical analysis of results from the dif- plants; this was compared using three dif- of varying ages. Coincidentally with
ferent aspects of this questionnaire did not ferent instruments: OHIP-14, OIDP, and our findings, not all categories were equally
show statistical differences between the WHOQOL-BREF. The reason for using all beneficial, except for teeth and oral
periods before and after surgery, contradict- three simultaneously was the interest to cavity cleaning, relaxing, and performing
ing results from the other two question- obtain a wider range of information not just daily tasks. It is worth considering that
naires: OHIP-14 and OIDP. restricted to oral health, specifically ad- an individual’s personality influences

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Berretin-Felix et al . Quality of life of elderly with implant-supported prostheses
the level of satisfaction derived from using
implants (Hantash et al. 2006).
Different from the previous instruments,
WHOQOL was not able to identify any
significant level of improvement in QL due
to treatment at the three analyzed periods,
namely 3, 6, and 18 months after surgery.
A possible reason for this disagreement
with the other two questionnaires was
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