Journal of Oral Rehabilitation 2006 33; 323–329

Quality of life and masticatory function in denture wearers
H. KOSHINO*, T. HIRAI*, T. ISHIJIMA*, H. TSUKAGOSHI*, T. ISHIGAMI† & Y . T A N A K A ‡ *Department of Removable Prosthodontics, School of Dentistry, Health Sciences University of Hokkaido,
Removable Partial Denture, School of Dentistry, Aichi-Gakuin University, Nagoya, Japan IshikariTobetsu, Japan, †Department of Removable Partial Denture, School of Dentistry, Nihon University, Tokyo, Japan and ‡Department of

SUMMARY Successful prosthodontic treatments for a patient with removable partial dentures including maxillofacial prostheses hopefully brings about psychological wellbeing as well as improved health. The purpose of this study was to investigate the relationship between quality of life (QOL) and the various aspects of denture function. At first, a questionnaire with a visual analog scale with 16 question items concerning denture and/or eating problems, the present state of health, psychological and physical wellbeing, life satisfaction, and QOL was developed. To discuss the validity and reliability of the questionnaire, 48 outpatients who wore a denture were asked to fill it out. Next, to discuss the difference in QOL of the patient with various kinds of dentures and conditions, 103 outpatients were

asked to complete the newly developed questionnaire. The questionnaire which contained four factor areas with eight questions for denture patients was developed by factor analysis with Varimax rotation. The reliability of the QOL scale was confirmed by reliability analysis (Cronbach’s a = 0Æ784). The QOL score of edentulous patients with a complete denture having some trouble chewing was significantly lower than that of other denture patients. It was suggested that the wearing of a denture significantly affected the QOL of elderly persons. KEYWORDS: QOL, denture wearers, prosthodontic treatment, elderly person Accepted for publication 19 March 2002

Introduction
Epidemiological surveys in recent years have revealed the close relationship between oral health status and quality of life (QOL) (1–3). Osterberg et al. (4) reported that dental impairment was associated significantly with a lower capacity for cognition, sight, hearing, lung volume, heart volume, muscle strength and bone mineral content, as well as an overall self-assessment of health. They also reported that the amount of occlusal support in men was related to the survival rate in those subjects who were between 70 and 79 years of age. Yamamoto (5) reported the close relationship between QOL and exercise and/or sports. We confirmed through our research that a close relationship exists between teeth clenching and physical exercise, such as elbow flexion strength, knee
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extension strength, back strength, maximal anaerobic power activity, and reaction time in a vertical jump (6–8). A previous study on rats also suggested that the decrease of masticatory function caused by tooth loss leads to a decrease in cerebral blood flow volume and acetylcholine synthesis resulting in a learning memory disorder similar to the symptom displayed in dementia (9). Another investigation suggested that ageing, soft diet, malnutrition and loss of occlusal support could accelerate osteoporotic changes of the mandibular bone and femur, and cause a decrease of bodily activities and sensory deprivation (10). From the above results, we have speculated that the recovery of occlusion and/or dental arch by prosthodontic treatment are important factors to secure QOL. The need to find accurate, reliable indicators on which to base planning, provision and evaluation of health services has given impetus
doi: 10.1111/j.1365-2842.2005.01152.x

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to the continued search for accurate information. The development of simple standardized indicators of QOL is thus important in the assessment of health services and health care. Successful prosthodontic treatments for a patient with removable partial dentures including maxillofacial prostheses are supposed to bring about psychological wellbeing as well as improved health and/or a sense of wellness. It is necessary to establish the objective criteria for judging the contribution of prosthodontic treatments for patients. The purpose of this study was to investigate the relationship between the QOL and denture function. from these subjects participating in this study. The list of questions had an analog scale with straight lines (10 cm in length), a random question sequence and a reversed polarity of questions, the so-called visual analog scale (VAS). Filling out of the items was performed by way of an interview. The evaluation was carried out by points, each represented by 10 cm.

Statistical analysis Statistical analysis of the validity and reliability of the each item in the questionnaire were performed by the factor and reliability analysis (SPSS for Windows 9.0, SPSS Inc.).

Development of QOL scale for denture wearers
Method To measure QOL of denture wearers, an index the QOLD was developed by the authors. This was composed of 16 questions suggested by Padilla and Grant (11) concerning denture and/or eating problems, present state of health, psychological and physical wellbeing, life satisfaction, and QOL (Table 1). Forty-eight outpatients with either maxillofacial prostheses (17 persons) and/or complete dentures (31 persons) in our university hospitals were asked to fill out a questionnaire. Informed consent was obtained

Results Five factors were obtained by the factor analysis with Varimax rotation, and the results of Q4 and Q13 were eliminated. After that, the factor analysis with Varimax rotation was performed again. Four factors were obtained, which could be classified as psychological health (Psy), physical health (Phy), eating satisfaction (Eat) and pain experienced with denture use (Den) (Table 2). Two high-loading items for each factor were selected (Table 3). In the questionnaire with four factors composed of eight questions, the reliability coefficient (Cronbach’s a) was 0Æ784.
Table 2. Factor analysis with Varimax rotation matrix (second rotated component)

Table 1. Sixteen items of QOLD for denture wearers Component Q1. How much physical strength do you feel you have? Q2. Is the amount of time you sleep sufficient to meet your needs? Q3. Do you tire easily? Q4. Do you feel your present weight is a problem? Q5. How would you rate your present state of health? Q6. How much fun do you have (hobbies, recreation, social activities)? Q7. Do you find eating a pleasure? Q8. Is the amount you eat sufficient to meet your needs? Q9. How useful do you feel? Q10. How much happiness do you feel? Q11. How satisfying is your life? Q12. How good is the quality of your life? Q13. Do you worry (fearful or anxious) about your denture? Q14. How much pain do you feel when wearing your denture? Q15. How often do you feel pain when wearing your denture? Q16. Do you have any concern about bad odors being emitted from your denture? 1 Q1 Q2 Q3 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q14 Q15 Q16 0Æ250 0Æ016 0Æ131 0Æ134 0Æ835* 0Æ240 0Æ168 0Æ177 0Æ856* 0Æ771* 0Æ784* 0Æ243 0Æ096 0Æ762* 2 0Æ542* 0Æ691* 0Æ804* 0Æ791* 0Æ334 )0Æ005 0Æ091 0Æ603* 0Æ220 0Æ101 0Æ291 0Æ028 0Æ106 )0Æ038 3 )0Æ028 0Æ237 )0Æ368 0Æ006 0Æ246 0Æ842* 0Æ900* 0Æ296 0Æ332 0Æ436 0Æ144 0Æ105 0Æ258 )0Æ200 4 0Æ149 )0Æ096 )0Æ055 0Æ064 0Æ016 0Æ267 0Æ130 0Æ350 )0Æ039 0Æ221 0Æ271 0Æ921* 0Æ915* 0Æ209

*Questions selected. Text in bold; 2 high-loading items selected.

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QUALITY OF LIFE AND MASTICATORY FUNCTION
Table 3. Components and questions 1. Psychological health (Psy) Q6. How much fun do you have (hobbies, recreation, social activities)? Q10. How much happiness do you feel? 2. Physical health (Phy) Q3. Do you tire easily? Q5. How would you rate your present state of health? 3. Eating satisfaction (Eat) Q7. Do you find eating a pleasure? Q8. Is the amount you eat sufficient to meet your needs? 4. Pain by denture (Den) Q14. How much pain do you feel when wearing your denture? Q15. How often do you feel pain when wearing your denture?

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Statistical analysis Statistical analysis of the difference in each group was performed by one-way analysis of variance (ANOVA) with multiple range test (Duncan) (SPSS for Windows 9.0, SPSS Inc.). A correlation among factors was performed by simple linear regression analysis (SPSS for Windows 9.0, SPSS Inc.).

Results Regarding the average age of each group, there was no statistical difference among the TFD group, NFD group, SFD group and NPD group. However, the average age of the NMP group was statistically lower than that of the other four groups. Figure 1 shows the score of four factors (Psy, Phy, Eat and Den) of the QOLD, the ‘QOLD score’. The ‘MS score’ in each group were 25Æ9 Æ 13Æ9, 55Æ7 Æ 23Æ6, 65Æ5 Æ 20Æ8, 69Æ8 Æ 21Æ7, 57Æ6 Æ 20Æ5%, respectively. The ‘MS score’ in the TFD group was statistically lower than that of the other four groups. As to the average of Psy score, Eat score, Den score and MS score in each group, the score of the TFD group was significantly lower than that of other groups. Moreover, in this group, the average of Phy score was the lowest among all the groups, although it was not significant. As a result, the QOLD score of the TFD group was significantly lower than that of other groups. The Den score was the lowest among the four factors in this group. The correlation among the score of the four factors, the QOLD score and the MS score were analysed. The relationship between the four factors and the QOLD score (Fig. 2), Phy score and Psy score, Psy score and Eat score, Eat score and Den score (Fig. 3), the MS score and the four factors (Fig. 4), and MS score and QOLD score (Fig. 5) were statistically significant.

QOLD in the patients with various kinds of dentures
Method One hundred and three outpatients in our university hospitals with various kinds of dentures were asked to fill out the QOLD questionnaire. Informed consent was obtained from these subjects participating in this study. They were divided into five groups. They were (i) 10 edentulous patients with complete denture having some trouble chewing and diagnosed as requiring prosthodontic treatment (TFD; mean age 77Æ0 Æ 11Æ3 years), (ii) 23 fully edentulous patients with newly fabricated complete dentures that had been adjusted (NFD; mean age 77Æ5 Æ 6Æ7 years), (iii) 21 single edentulous patients with newly fabricated upper or lower complete dentures that had been adjusted (SFD; mean age 73Æ7 Æ 8Æ3 years), (iv) 31 partially edentulous patients with newly fabricated removable partial dentures that had been adjusted (NPD; mean age 67Æ4 Æ 9Æ7 years), and (v) 18 patients with defective jaws and newly fabricated maxillofacial prostheses that had been adjusted (NMP; mean age 59Æ2 Æ 17Æ7 years). The score of the QOLD in each patient was represented by showing the VAS on a 10-cm line. Each score of four factors in the QOLD was represented by the average point of two question items. The ‘QOLD score’ was represented by the average score of four factors. ‘Masticatory score’ (MS score) was also calculated by using the food intake questionnaire method developed by the authors for complete denture wearers (12). In this study, the questionnaire on eating was answered during a personal interview with the authors.

Discussion
Quality of life measurements are used to justify or refute different forms of medical treatment (13). Presant et al. (14) and Padilla et al. (15) developed a multidimensional instrument for measuring QOL, and reported that initial testing of the model using data from 135 colostomy patients showed how satisfaction regarding nursing care and personal control act as cognitive mediators of self-worth, which then impacts the dimensions of QOL.

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Fig. 1. The score of four factors (Psy, Phy, Eat and Den) of the QOLD, the QOLD scores in each group.

Fig. 2. Relationships between QOLD score and four factors.

It is necessary to find evidence that prosthodontic treatments improve the QOL of denture patients. The QOLD developed by the authors was judged to be reliable, because the reliability coefficient was 0Æ784. As to the procedure for developing QOLD, five factors including 16 question items were obtained by the firstfactor analysis. In the factor analysis, the order of five factors is based on factor loading levels. The fifth factor

had the lowest loading level and there was no common context in questions Q4 and Q13. Then, Q4 and Q13 were eliminated. Next, four factors including 14 question items were obtained by the second-factor analysis. Four factors seemed to best represent question items. It was possible to group the items under Psy, Phy, Eat and Den. In the factor analysis, the factor loading level was influenced by the number of question items. To

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Fig. 3. Relationships between ‘Phy’ and ‘Psy’, ‘Psy’ and ’Eat’, ‘Eat’ and ’Den’.

Fig. 4. Relationships between MS score and the four factors.

standardize each factor, two high-loading items in each factor were selected for the QOLD questionnaire. Finally, the reliability analysis was performed for the

questionnaire with four factors composed of eight question items. The reliability of this method was then confirmed.

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proper denture insertion enhances the degree of eating satisfaction, and the significant correlation with Psy score and Eat score suggests that eating satisfaction contributes to psychological health (Fig. 4). It is also speculated that the significant correlation with Phy score and Psy score suggests that there is a close connection between the physical health factor and the psychological health factor (Fig. 4). Because the MS score was correlated statistically with the score of four factors and the QOLD score, proper denture insertion is speculated to be important to bring about overall wellbeing (Fig. 5).
Fig. 5. Relationship between the MS score and QOLD score.

Conclusion
It has been suggested that eating satisfaction and the feel of comfort when chewing with dentures has influence on physiological and psychological health. Moreover, it has been suggested that the wearing of a denture significantly affected the QOL of elderly persons.

In order to discuss the difference in QOL of the patient with various kinds of dentures and conditions, 103 outpatients were asked to fill out the questionnaire newly developed by the authors. In the five groups, the average age of the NMP group was significantly younger than that of other groups. The reason for this may have been that the defective jaw with tooth loss is often caused by a surgical operation and/or a traffic accident and not by ageing. In the TFD group, Phy score and Psy score were statistically low in comparison with other groups (Fig. 1). These results suggest that recovery of the masticatory function is essential to keep a sound mind and body. Unexpectedly, the QOLD score of NMP group was almost the same as the NFD, SFD and NPD group (Fig. 1). This result suggests that the QOL of patients with defective jaws could be improved by the appropriate maxillofacial prostheses. As previously mentioned, the relationship between the four factors (Psy, Phy, Eat and Den) and the QOLD score, Phy score and Psy score, Psy score and Eat score, Eat score and Den score, the MS score and the four factors, and MS score and QOLD score were statistically significant (Figs 2–5). The MS score representing the masticatory ability of complete denture wearers had already been verified to be effective and the relationship between the food intake questionnaire method and the sieving method suggested by Kapur and Yurkstas (16) had been significantly correlated (12, 17, 18). Therefore, in this study, the food intake questionnaire method was used to evaluate the masticatory ability. It is speculated that the significant correlation with Eat score and Den score suggests that

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Correspondence: Hisashi Koshino, Department of Removable Prosthodontics, School of Dentistry, Health Sciences University of Hokkaido, 1757 Kanazawa, Ishikari-Tobetsu, Hokkaido, Japan 061-0293. E-mail: koshino@hoku-iryo-u.ac.jp

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 323–329

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