Cochrane Database of Systematic Reviews

Interventions for missing teeth: Removable prostheses for the

edentulous mandible (Protocol)

Jahangiri L, Choi M, Moghadam M, Jawad S

Jahangiri L, Choi M, Moghadam M, Jawad S.

Interventions for missing teeth: Removable prostheses for the edentulous mandible.
Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD011544.
DOI: 10.1002/14651858.CD011544.

www.cochranelibrary.com

Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol) i
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Interventions for missing teeth: Removable prostheses for the

edentulous mandible

Leila Jahangiri1 , Mijin Choi1 , Marjan Moghadam1 , Sarra Jawad2

1 Department of Prosthodontics, College of Dentistry, New York University, New York, USA. 2 University Dental Hospital of Manchester,

Manchester, UK

Contact address: Leila Jahangiri, Department of Prosthodontics, College of Dentistry, New York University, 345 East 24th Street,
Room 415-S, New York, 10010, USA. lj14@nyu.edu.

Editorial group: Cochrane Oral Health Group.

Publication status and date: New, published in Issue 2, 2015.

Citation: Jahangiri L, Choi M, Moghadam M, Jawad S. Interventions for missing teeth: Removable prostheses for the edentulous
mandible. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD011544. DOI: 10.1002/14651858.CD011544.

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effects of no treatment, treatment with conventional removable complete denture, and treatment with implant-retained
removable prosthesis for the rehabilitation of edentulous mandibles.

BACKGROUND
Description of the condition
Edentulism is a state of having no teeth at all (Glossary of
Prosthodontic Terms 2005), and is considered by the World
Health Organization (WHO) to be a disability (WHO 2014). It
may result from not developing teeth in the first instance (true
or total anodontia), but this condition is exceedingly rare. More
commonly, edentulism is the result of permanent tooth extrac-
tion in adulthood, which may or may not be due to caries, pe-
riodontal disease, trauma or other orofacial pathology (e.g. cysts,
tumours). As tooth loss increases with age, older adults (over 65)
are more prone to edentulism than younger adults, with propor-
tionately higher prevalences in subsequent decades (Steele 2009).
This means that this condition exists most frequently in a poten-
tially vulnerable group with complex needs (Muller 2014).
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Once teeth are extracted or lost, the jaw bones undergo degenera-
tive changes in size and shape that continue for the duration of the
individual’s life. This irreversible chronic disease is a phenomenon
well recognised as a pathological process (Atwood 1971) and is
termed residual ridge resorption or remodelling. This resorption
can lead to a poor foundation for complete denture prostheses.
Edentulous mandibles (lower jaws) are particularly significant as
the horseshoe-shaped remaining bone (residual ridge) has a smaller
surface area when compared to the maxilla (upper jaw), which re-
lies heavily on the surface area of the palate to establish a periph-
eral seal and thus retain a complete denture. The mandibular den-
ture is hampered by the presence of the moving tongue and orofa-
cial muscles which tend to dislodge the denture during function.
Furthermore, over time the mandibular residual ridge continues
to resorb (Tallgren 1972), and is affected four times more signif-
icantly than the maxillary arch (Landa 1967), resulting in even
more potential difficulty in wearing lower dentures. In fact, the
most common complaint of patients wearing complete dentures
1
is related to lack of retention of the mandibular prosthesis. This
resorption has been classified in different ways. The Atwood/Ca-
wood and Howell classifications (Atwood 1963; Cawood 1988)
represent a scale of I-VI, with class I representing a mandible with
a tooth in place and optimum bone support, progressing to class
V and VI, where the bone has resorbed significantly. The Amer-
ican College of Prosthodontists (ACP) (McGarry 1999) classifies
the status of edentulous arches with a rating of 1, 2, 3, or 4 (1
being simplest to treat and 4 being the most complex), based on
the alveolar bone height, bone shape, types of overlying gingival
tissues, jaw relationships, need for adjunctive surgical procedures,
amount of available space between the lower and upper jaws, and
other underlying systemic and psychosocial conditions of patients.
For instance, lower jaws with 10 mm or less of vertical bone height
with an unfavourable shallow floor of the mouth are considered
to belong in the least favourable category, class 4. These cases (Ca-
wood and Howell VI, ACP 4) are anatomically least likely to be
able to tolerate a lower denture.
Confounding these factors is the patient’s relative ability to adapt to
a prosthesis, which has been shown to decrease with age (Carlsson
2010), be influenced by psychological (Eitner 2006) and cultural
factors (Scott 2001), and is irrespective of the perceived quality of
the prosthesis (Garrett 1996; Heydecke 2003). As a result, many
edentulous patients lack comfort with their prostheses, resulting
in an impaired ability to chew. This affects their nutritional intake,
which, in turn, affects their general health (Oral Health in America
2000).
Edentulism has been linked to systemic conditions such as car-
diovascular disease (Dietrich 2008; Joshipura 1996), stroke (Elter
2003), cancer (Divaris 2010; Guha 2007), and mortality (Abnet
2005). The social behaviour of the edentulous population is also
altered as the confidence and ability to eat with others is affected.
The quality of life of many patients in this vulnerable ageing pop-
ulation is compromised. Edentulism is a global phenomenon, and
there is wide variation in prevalence, both between countries and
within them. In the USA, Canada, Australia, and the United King-
dom, the prevalence of edentulism in the general population is
around 6% to 8% (Dye 2012; Emami 2013; Sanders 2004; Steele
2009; Wu 2012), rising to 20% to 26% in the over 65 year-old
age group. The prevalence of edentulism in India, Mexico, Russia,
China, Ghana, and South Africa is reported to be 11.7% (Peltzer
2014). However, in lower- and middle-income countries, parts
of rural India, Brazil, and Turkey for example, the rate can be
as high as 48% to 60% of the elderly population (Emami 2013;
Hugo 2007; Kaira 2014). However, these studies are on relatively
small samples and more studies are required in these regions to
decipher the true rate and reasons for such wide variation. So-
cioeconomic factors have been shown to be associated with varia-
tions in the prevalence of edentulism, with one Canadian study re-
porting a six-fold increase in edentulism in poorer cohorts (Miller
2005). With the average life expectancies increasing globally, the
burden of edentulism is increasing, as those who are edentulous
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
live to an older age. Edentulism is also linked to poorer general
health (Douglass 2002; Felton 2009). Therefore, management of
the edentulous patient has become a public health concern (Polzer
2010).
Description of the intervention
Edentulous patients can be left untreated, or treated in several
ways: with provision of complete dentures; with implant-retained
prostheses; or with implant-supported prostheses.
For centuries, complete denture prostheses have been considered
the first-line of treatment for edentulism, providing the individual
with prosthetic teeth to enable mastication (chewing), optimise
speech, and restore aesthetics. In most cases, edentulous patients
are provided with complete dentures alone, which the majority
have tolerated to varying degrees. These are defined as artificial
prostheses which “substitute for missing natural teeth and soft tis-
sues” (Glossary of Prosthodontic Terms 2005), held in place by ad-
hesion and cohesion on supporting tissues. In some cases, prepros-
thetic surgery to optimise the denture-bearing area has been ad-
vocated, but a Cochrane review has found weak evidence that the
provision of dental implants are preferable (Coulthard 2002). Na-
tional (Thomason 2009) and international consensus statements
(Feine 2002) have suggested that the provision of two dental im-
plants in the mandible (to retain a removable overdenture), should
be the first choice of treatment due to the recognised improve-
ments in quality of life of this intervention. Furthermore a stan-
dard of care for the optimal treatment of the edentulous mandible
has been proposed in the USA (Das 2012). However, this inter-
vention has yet to be analysed in a structured systematic review,
and has not been compared to possible alternatives, such as a con-
ventional complete denture or no treatment. Further, there are
differing opinions on the number of implants necessary and the
types of attachments to removable prostheses.
How the intervention might work
Dental implants work by integrating with the surrounding bone,
forming anchors to which removable or fixed prostheses can at-
tach. Since the 1960s, use of dental implants has been recognised
as a method for rehabilitating the mouth following loss of teeth
(Branemark 1983). The implant itself replaces the lost tooth root.
Overlying structures attach to the implant(s) and are termed the
’prosthetic components’. These components can be connected to
the implant in a manner in which the prosthesis cannot be removed
by the patient: fixed implant-supported prosthesis. However, the
prosthetic components can also be connected to the implant with
attachment mechanisms that allow insertion and removal by the
patient: implant-retained prosthesis (Glossary of Prosthodontic
Terms 2005). This review will only focus on the latter - the im-
plant-retained (removable) mandibular prosthesis.
2
Why it is important to do this review
It is important to do this review to compare treatment meth-
ods for the management of the edentulous mandible. Edentulous
mandibles are considered debilitating and therefore effective re-
habilitation using current evidence is indicated. Edentulous indi-
viduals have the choice of no prosthesis, a conventional remov-
able prosthesis, an implant-retained removable prosthesis or an
implant-supported fixed prosthesis. There are risks and benefits to
each treatment modality, but these have not been formally anal-
ysed through a Cochrane systematic review. There may be varia-
tions in optimal treatments depending on patient age, extent of
ridge resorption, and the condition of the opposing arch (edentu-
lous/dentate maxilla).
Optimal treatment of the edentulous mandible is a topic of great
clinical importance for dental practitioners. The review authors
have extensive experience in the implementation of related treat-
ment protocols in the clinical setting, and are able to promote
translation of the findings of this systematic review into dental
education, and ultimately the practice of dentistry.
OBJECTIVES
To assess the effects of no treatment, treatment with conven-
tional removable complete denture, and treatment with implant-
retained removable prosthesis for the rehabilitation of edentulous
mandibles.
METHODS
Criteria for considering studies for this review
Types of studies
Randomised controlled trials (RCTs) investigating no treatment,
treatment with a conventional removable complete denture, and
treatment with an implant-retained removable prosthesis for the
rehabilitation of edentulous mandibles. Because of the nature of
the intervention, cross-over designs and split-mouth studies are
inappropriate and we will exclude such studies.
Types of participants
Participants with edentulous mandibles (adults and children).
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Types of interventions
We will include the following types of interventions.
• No treatment.
• Treatment with conventional removable prosthesis
(complete denture) (Glossary of Prosthodontic Terms 2005).
• Treatment with implant-retained removable prosthesis
(complete overdenture) secured by one or more dental implants
(Glossary of Prosthodontic Terms 2005.
Types of outcome measures
Primary outcomes
• Oral health-related and general quality of life
(encompassing but not exclusive to: patient satisfaction/comfort,
appearance, maintainability (hygiene) - as measured by validated
questionnaires).
Secondary outcomes
• Function/chewing ability (as measured by questionnaires or
objective means, e.g. chewing tests).
• Diet/nutrition (as measured by biochemical markers, body
mass index (BMI), validated questionnaires).
• Prosthetic complications (as measured by frequency of
prosthesis or prosthetic tooth fracture, prosthesis-induced
oromucosal conditions, prosthesis-induced ridge resorption).
• Implant-related complications (as measured by frequency of
peri- or post-implant placement complications, e.g. mandibular
fracture, nerve damage, haemorrhage, implant failure, peri-
implantitis).
• Cost-effectiveness (as measured by adjusted quality of life
years (QALYs) or disability adjusted life years (DALYs) or other
appropriate measure).
• Maintenance (as measured by frequency of prosthodontic
maintenance and/or patient satisfaction and quality of life
questionnaires).
We will consider all outcome measures in the short-term (less than
one year), medium-term (one to five years), and long-term (more
than five years).
Search methods for identification of studies
For the identification of studies included or considered for this
review, we will develop detailed search strategies for each database.
These will be based on the search strategy developed for MED-
LINE (OVID) (see Appendix 1) but revised appropriately for each
database. We will combine this search strategy with the Cochrane
3
Highly Sensitive Search Strategy for identifying randomised tri-
als in MEDLINE: sensitivity maximising version as referenced in
Chapter 6.4.11.1 and detailed in box 6.4.c of the Cochrane Hand-
book for Systematic Reviews of Interventions (Higgins 2011). We
will link the search of EMBASE to the Cochrane Oral Health
Group filter for identifying RCTs.
Electronic searches
We will search the following electronic databases.
• The Cochrane Oral Health Group’s Trials Register (to
present).
• The Cochrane Central Register of Controlled Trials
(CENTRAL, latest issue).
• MEDLINE via OVID (1946 to present) (see Appendix 1).
• EMBASE via OVID (1980 to present).
We will not impose any restrictions on date of publication when
searching the electronic databases.
Searching other resources
Unpublished trials
We will search the following databases for ongoing trials.
• US National Institutes of Health Trials Register (http://
clinicaltrials.gov).
• The WHO Clinical Trials Registry Platform (http://
apps.who.int/trialsearch/default.aspx).
We will screen the bibliographies of included papers, and check
relevant review articles for studies not identified by the search
strategies above.
Language
We will not apply any language restrictions in the electronic
searches. Any non-English trials that we identify will be translated
through The Cochrane Collaboration.
Data collection and analysis
Selection of studies
We will independently identify titles and abstracts of studies meet-
ing the criteria from initial electronic sources to determine any po-
tentially eligible studies. All authors will be involved in the screen-
ing procedure. We will carry out a full text evaluation on the stud-
ies that fulfil the inclusion criteria to determine if we will include
or exclude them. When there is insufficient detail in the study ti-
tle and abstract to determine whether a study fulfils the inclusion
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
criteria, the review authors will obtain and independently assess
the full report. We will contact authors if clarification is needed
on the conduct of the studies. We will link multiple reports of the
same study under one study name. We will further refine litera-
ture after the initial data extraction. Any inclusion ambiguity will
be discussed between members of the review. If consensus cannot
be reached, we will consult the Cochrane Oral Health Group to
achieve consensus. We will provide the rationale for exclusion in
the Characteristics of excluded studies table. A PRISMA study
flow chart will be created to summarise this process.
Data extraction and management
All review authors will be involved in data extraction. At least two
review authors will independently, and in duplicate, evaluate each
study using the data extraction form that has been piloted on a
small number of studies. We will contact authors where clarifica-
tion is needed on the conduct of the studies. We will link multiple
reports of the same study under one study name. For each study
with more than one control or comparison group for the inter-
vention, we will extract the results for each intervention arm.
We will record the following information for each of the included
studies.
• Year of publication, country of origin, study design,
number of centres.
• Details of participants (demographic characteristics),
inclusion and exclusion criteria, any relevant health information.
• Details of the type of intervention and comparison.
• Details of outcomes reported, including method and time
of assessment, as well as adverse effects.
Assessment of risk of bias in included studies
At least two review authors will assess the risk of bias in included
studies using The Cochrane Collaboration’s tool for assessing risk
of bias based on the Cochrane Handbook for Systematic Reviews
of Interventions (Higgins 2011). Authors will assess bias indepen-
dently. Where authors disagree about the risk of bias in different
studies, disagreements will be resolved by discussion and subse-
quent majority opinion.
The domains that we will assess for each included study will be:
1. sequence generation (selection bias);
2. allocation concealment (selection bias);
3. blinding of participants and personnel (performance bias);
4. blinding of outcome assessment (detection bias);
5. completeness of outcome data (attrition bias);
6. selective outcome reporting (reporting bias); and
7. risk of other potential sources of bias (other bias).
The Cochrane Collaboration’s tool for assessing risk of bias is a
two-part tool, the first part describing what happened in the re-
view, and the second part a judgement on the risk of bias based
on the description. For example, in the case of allocation conceal-
ment, the reviewer criteria for assessing risk of bias will be:
4
 1. low risk of bias (adequate concealment of the allocation
(e.g. sequentially numbered, sealed, opaque envelopes or
centralised or pharmacy-controlled randomisation);
2. unclear risk of bias (unclear about whether the allocation
was adequately concealed (e.g. where the method of concealment
is not described or not described in sufficient detail to allow a
definite judgement)); and
3. high risk of bias (inadequate allocation concealment (e.g.
open, random number lists or quasi-randomisation such as
alternate days, date of birth, or case record number).
We will tabulate a description of all of the above seven domains for
each included trial, along with a judgement of the risk of bias (low,
high or unclear). We will provide a summary assessment of the
risk of bias for the primary outcome across the studies (Higgins
2011). For each study, we will assess according to the following
rationale.
1. Low risk of bias, when there is a low risk of bias across all
seven key domains.
2. Unclear risk of bias, when there is an unclear risk of bias in
one or more of the seven key domains.
3. High risk of bias, when there is a high risk of bias in one or
more of the seven key domains.
We will summarise the risk of bias in the review and present it
in tabulated form and graphically. We will take into account the
number of studies with high risk of bias in the interpretation of
results. If a large number of studies are considered at high risk of
bias, we will employ a narrative description of results.
Measures of treatment effect
For dichotomous outcomes (e.g. complications: yes/no), we will
express the estimate of effect of an intervention as risk ratios (RRs)
together with 95% confidence intervals (CIs). For continuous out-
comes (e.g. quality of life reported on a visual analogue scale), we
will use mean differences (MDs) and 95% CIs to summarise the
data; in the event that different studies measure outcomes using
different scales, we will express the estimate of effect of an inter-
vention as standardised mean differences (SMDs) and 95% CIs.
Unit of analysis issues
The patient will be the unit of analysis. Where cluster randomised
trials are included, we will undertake data analysis, whenever fea-
sible, at the same level as the randomisation, or at the individual
level accounting for the clustering.
Dealing with missing data
We will contact authors of studies for clarification if there is data
missing from the study, and the report was published from the
year 2000 or onwards. We consider it unfeasible to obtain data for
trials published prior to this cut-off date. We will use methods as
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
outlined in the Cochrane Handbook for Systematic Reviews of Inter-
ventions to estimate missing standard deviations (Higgins 2011).
Assessment of heterogeneity
If it is appropriate that meta-analyses will be performed, we will
assess the possible presence of heterogeneity visually by inspecting
the point estimates and CIs on the forest plots; if the CIs have
poor overlap then we will consider heterogeneity to be present. We
will also assess heterogeneity statistically using a Chi2 test, where
a P value < 0.1 will indicate statistically significant heterogeneity.
Furthermore, we will quantify heterogeneity using the I2 statistic.
A guide to interpretation of the I2 statistic as per Section 9.5.2 of
the Cochrane Handbook for Systematic Reviews of Interventions is as
follows (Higgins 2011).
• 0% to 40%: might not be important.
• 30% to 60%: may represent moderate heterogeneity.
• 50% to 90%: may represent substantial heterogeneity.
• 75% to 100%: considerable heterogeneity.
Assessment of reporting biases
If there are a sufficient number of trials (more than 10) included
in any meta-analysis, we will assess publication bias according
to the recommendations on testing for funnel plot asymmetry
as described in the Cochrane Handbook for Systematic Reviews of
Interventions (Higgins 2011).
Data synthesis
Using RevMan 5.3 software (RevMan 2014), we will perform
meta-analysis of studies assessing the same comparisons and out-
comes if appropriate. We will combine RRs for dichotomous out-
comes, and MDs (or SMDs if different scales are used) for con-
tinuous outcomes, using a random-effects model where there are
four or more studies, or a fixed-effect model if there are less than
four studies. We will present data from studies not included in
meta-analyses in an additional table.
Subgroup analysis and investigation of heterogeneity
As appropriate, we will pursue subgroup analysis according to:
• anatomical classification of edentulous ridge;
• age of patient;
• presence/type of prosthesis in opposing dentition.
Sensitivity analysis
If the number of studies allows, we will undertake a sensitivity
analysis for each intervention and outcome, limiting the analysis
to studies at overall low risk of bias.
5
Presentation of main results
We will generate a ’Summary of findings’ table for each compar-
ison and for the important outcomes in accordance with section
11.5 of the Cochrane Handbook for Systematic Reviews of Interven-
tions (Higgins 2011) using the GRADE methods (GRADE 2004)
and the GRADEPro software package (GRADEpro 2008). The
outcomes we will include are: Prosthetic/implant complications,
quality of life, chewing ability, diet/nutrition, and cost-effective-
ness.
We will assess the quality of the body of evidence for each com-
parison and outcome by considering the overall risk of bias of the
REFERENCES
Additional references
Abnet 2005
Abnet CC, Qiao YL, Dawsey SM, Dong ZW, Taylor RR,
Mark SD. Tooth loss is associated with increased risk of
total death and death from upper gastrointestinal cancer,
heart disease, and stroke in a Chinese population-based
cohort. International Journal Epidemiology 2005;34(2):
467–74. [DOI: 15659476]
Atwood 1963
Atwood DA. Postextraction changes in adult mandible as
illustrated by microradiographs of midsagittal sections and
serial cephalometric roentgenograms. Journal of Prosthetic
Dentistry 1963;13(5):810–24. [DOI: 10.1016/0022-3913
(63)90225-7]
Atwood 1971
Atwood DA. Reduction of residual ridges - major oral
disease entity. Journal of Prosthetic Dentistry 1971;26(3):
266–79. [DOI: 10.1016/0022-3913(71)90069-2]
Branemark 1983
Branemark PI, Adell R, Albrektsson T, Lekholm U,
Lundkvist S, Rockler B. Osseointegrated titanium fixtures
in the treatment of edentulousness. Biomaterials 1983;4(1):
25–8.
Carlsson 2010
Carlsson GE, Omar R. The future of complete dentures
in oral rehabilitation. A critical review. Journal of Oral
Rehabilitation 2010;37(2):143–56. [DOI: 10.1111/
j.1365-2842.2009.02039.x.]
Cawood 1988
Cawood JI, Howell RA. A classification of the edentulous
jaws. International Journal of Oral and Maxillofacial
Surgery 1988;17(4):232–6. [DOI: 10.1016/S0901-5027
(88)80047-X]
Coulthard 2002
Coulthard P, Esposito M, Worthington HV, Jokstad A.
Interventions for replacing missing teeth: preprosthetic
surgery versus dental implants. Cochrane Database
of Systematic Reviews 2002, Issue 4. [DOI: 10.1002/
14651858.CD003604]
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
included studies, the directness of the evidence, the inconsistency
of the results, the precision of the estimates, and the risk of publi-
cation bias. We will categorise the quality of each body of evidence
as high, moderate, low, or very low.
ACKNOWLEDGEMENTS
Dr. Ivy Peltz, Department of Cariology and Comprehensive Care,
New York University College of Dentistry, New York, NY USA
Das 2012
Das KP, Jahangiri L, Katz RV. The first-choice standard of
care for an edentulous mandible: a Delphi method survey
of academic prosthodontists in the United States. Journal
of the American Dental Association 2012;143(8):881–9.
[PUBMED: 22855902]
Dietrich 2008
Dietrich T, Jimenez M, Krall Kaye EA, Vokonas PS,
Garcia RI. Age-dependent associations between chronic
periodontitis/edentulism and risk of coronary heart disease.
Circulation 2008;117(13):1668–74. [PUBMED: 10.1161/
CIRCULATIONAHA.107.711507]
Divaris 2010
Divaris K, Olshan AF, Smith J, Bell ME, Weissler MC,
Funkhouser WK, et al. Oral health and risk for head and
neck squamous cell carcinoma: the Carolina Head and
Neck Cancer Study. Cancer Causes Control 2010;21(4):
567–75.
Douglass 2002
Douglass C, Shih A, Ostry L. Will there be a need for
complete dentures in the United States in 2020?. Journal of
Prosthetic Dentistry 2002;87:5–8.
Dye 2012
Dye BA, Li X, Beltran-Aguilar ED. Selected oral health
indicators in the United States, 2005-2008. NCHS Data
Brief 2012;96:1–8.
Eitner 2006
Eitner S, Wichmann M, Heckmann J, Holst S. Pilot study
on the psychologic evaluation of prosthesis incompatibility
using the SCL-90-R scale and the CES-D scale. The
International Journal of Prosthodontics 2006;19:482–90.
Elter 2003
Elter JR, Offenbacher S, Toole JF, Beck JD. Relationship of
periodontal disease and edentulism to stroke/TIA. Journal
of Dental Research 2003;82(12):998–1001. [PUBMED:
14630902]
Emami 2013
Emami E, de Souza RF, Kabawat M, Feine JS. The impact
of edentulism on oral and general health. International
6
 Journal of Dentistry 2013 May 8 [Epub ahead of print].
[DOI: 10.1155/2013/498305]
Feine 2002
Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan
WJ, Gizani S, et al. The McGill consensus statement
on overdentures. Mandibular two-implant overdentures
as first choice standard of care for edentulous patients.
Gerodontology 2002;19(1):3–4.
Felton 2009
Felton DA. Edentulism and comorbid factors. Journal
of Prosthodontics 2009;18(2):88–96. [DOI: 10.1111/
j.1532-849X.2009.00437.x.]
Garrett 1996
Garrett NR, Kapur KK, Perez P. Effects of improvements
of poorly fitting dentures and new dentures on patient
satisfaction. Journal of Prosthetic Dentistry 1996;76:403–13.
Glossary of Prosthodontic Terms 2005
[No authors listed]. The glossary of prosthodontic terms.
Journal of Prosthetic Dentistry 2005;94(1):10–92. [DOI:
10.1016/j.prosdent.2005.03.013]
GRADE 2004
GRADE Working Group. Grading quality of evidence and
strength of recommendations. BMJ 2004;328(7454):1490.
GRADEpro 2008 [Computer program]
Brozek J, Oxman A, Schünemann H. GRADEpro. Version
3.2 for Windows 2008.
Guha 2007
Guha N, Baffetta P, Wünsch Filho V, Eluf Neto J, Shangina
O, Zaridze D, et al. Oral health and risk of squamous cell
carcinoma of the head and neck and esophagus: results of
two multicentric case-control studies. American Journal of
Epidemiology 2007;166(10):1159–73.
Heydecke 2003
Heydecke G, Klemetti E, Awad MA, Lund JP, Feine JS.
Relationship between prosthodontic evaluation and patient
ratings of mandibular conventional and implant prostheses.
The International Journal of Prosthodontics 2003;16:307–12.
Higgins 2011
Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. The Cochrane Collaboration,
2011. Available from www.cochrane-handbook.org.
Hugo 2007
Hugo FN, Hilgert JB, de Sousa Mda L, da Silva DD, Pucca
GA Jr. Correlates of partial tooth loss and edentulism
in the Brazilian elderly. Community Dentistry and Oral
Epidemiology 2007;35(3):224–32.
Joshipura 1996
Joshipura KJ, Rimm EB, Douglass CW, Trichopoulos D,
Ascherio A, Willett WC. Poor oral health and coronary
heart disease. Journal of Dental Research 1996;75(9):
1631–6.
Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kaira 2014
Kairaa LS, Dabral E. Prevalence of complete edentulism
among Udaipur population of India. The Saudi Journal for
Dental Research 2014;5(2):139–45.
Landa 1967
Landa JS. Classification of mandibular resorption.
Dental Radiography and Photography 1967;40(3):62–5.
[PUBMED: 5233507]
McGarry 1999
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith
CR, Koumjian JH. Classification system for complete
edentulism. The American College of Prosthodontics.
Journal of Prosthodontics 1999;8(1):27–39. [PUBMED:
10356552]
Miller 2005
Millar WJ, Locker D. Edentulism and denture use. Health
Reports 2005;17(1):55–8.
Muller 2014
Muller F. Interventions for edentate elders-what is the
evidence?. Gerodontology 2014;Suppl 1:44–51. [DOI:
10.1111/ger.12083]
Oral Health in America 2000
[No authors listed]. Oral health in America: a report of the
Surgeon General. Journal of the California Dental Association
2000;28(9):685–95.
Peltzer 2014
Peltzer K, Hewlett S, Yawson AE, Moynihand P, Preet R,
Wu F, et al. Prevalence of loss of all teeth (edentulism) and
associated factors in older adults in China, Ghana, India,
Mexico, Russia and South Africa. International Journal
of Environmental Research and Public Health 2014;11:
11308–24.
Polzer 2010
Polzer I, Schimmel M, Müller F, Biffar R. Edentulism
as part of the general health problems of elderly
adults. International Dental Journal 2010;60(3):143–55.
[PUBMED: 20684439]
RevMan 2014 [Computer program]
The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). Version 5.3. Copenhagen:
The Nordic Cochrane Centre, The Cochrane Collaboration,
2014.
Sanders 2004
Sanders AE, Slade GD, Carter KD, Stewart JF. Trends in
prevalence of complete tooth loss among Australians, 1979-
2002. Australian and New Zealand Journal of Public Health
2004;28(6):549–54.
Scott 2001
Scott BJ, Leung KC, McMillan AS, Davis DM, Fiske J. A
transcultural perspective on the emotional effect of tooth
loss in complete denture wearers. The International Journal
of Prosthodontics 2001;14:461–5.
Steele 2009
Steele JG, O’Sullivan I, The Health and Social Care
Information Centre. Executive Summary: Adult Dental
7
 Health Survey 2009. http://www.hscic.gov.uk/catalogue/
PUB01086/adul-dent-heal-surv-summ-them-exec-2009-
rep2.pdf 2010.
Tallgren 1972
Tallgren A. The continuing reduction of the residual alveolar
ridges in complete denture wearers: a mixed-longitudinal
study covering 25 years. Journal of Prosthetic Dentistry 1972;
27(2):120–32. [PUBMED: 4500507]
Thomason 2009
Thomason JM, Feine J, Exley C, Moynihan P, Mueller
F, Naert I, et al. Mandibular two implant-supported
overdentures as the first choice standard of care for
edentulous patients - the York Consensus Statement. British
Dental Journal 2009;207(4):185–6.
WHO 2014
World Health Organization. International Classification of
Functioning: Disability and Health (ICF). www.who.int/
classifications/icf/en/ 2014.
Wu 2012
Wu B, Liang J, Plassman BL, Remle C, Luo X. Edentulism
trends among middle-aged and older adults in the United
States: comparison of five racial/ethnic groups. Community
Dentistry and Oral Epidemiology 2012;40:145–53.
∗
Indicates the major publication for the study

APPENDICES

Appendix 1. MEDLINE (OVID) Search Strategy

1. exp Jaw, edentulous/
2. (jaw$ and edent$).ti,ab.
3. (mandib$ and edent$).ti,ab.
4. (mandib$ and resorb$).ti,ab.
5. “total tooth loss”.ti,ab.
6. or/1-5
7. Denture, complete/
8. (denture$ or overdenture$).ti,ab.
9. Dental Prosthesis, Implant-Supported/
10. (prosthes$ adj5 implant$).ti,ab.
11. Denture, Overlay/
12. or/7-11
13. 6 and 12
This search strategy will be combined with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MED-
LINE: sensitivity maximising version (2008 revision) as referenced in Chapter 6.4.11.1 and detailed in box 6.4.c of The Cochrane
Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011] (Higgins 2011).
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. randomized.ab.
4. placebo.ab.
5. drug therapy.fs.
6. randomly.ab.
7. trial.ab.
8. groups.ab.
9. or/1-8
10. exp animals/ not humans.sh.
11. 9 not 10

Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol) 8
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CONTRIBUTIONS OF AUTHORS
All authors have contributed to the development of this protocol.

DECLARATIONS OF INTEREST
Leila Jahangiri: none known
Mijin Choi: none known
Marjan Moghadam: none known
Sarra Jawad: none known

SOURCES OF SUPPORT

Internal sources
• No sources of support supplied

External sources
• National Institute for Health Research (NIHR), UK.
The NIHR is the largest single funder of the Cochrane Oral Health Group

Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR, NHS or the
Department of Health
• Cochrane Oral Health Group Global Alliance, Other.
The production of all our reviews is assisted by funding from our Global Alliance partners (http://ohg.cochrane.org/): British
Association for the Study of Community Dentistry, UK; British Association of Oral Surgeons, UK; British Orthodontic Society, UK;
British Society of Paediatric Dentistry, UK; British Society of Periodontology, UK; Canadian Dental Hygienists Association, Canada;
Mayo Clinic, USA; National Center for Dental Hygiene Research & Practice, USA; New York University College of Dentistry, USA;
and Royal College of Surgeons of Edinburgh, UK

Interventions for missing teeth: Removable prostheses for the edentulous mandible (Protocol) 9
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.