The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals

A critical review of diabetes, glycemic control, and dental implant therapy

OBJECTIVES

To systematically examine the evidence guiding the use of implant therapy relative to glycemic control for patients with diabetes and to consider the potential for both implant therapy to support diabetes management and hyperglycemia to compromise implant integration.

MATERIAL AND METHODS

A systematic approach was used to identify and review clinical investigations directly assessing implant survival or failure for patients with diabetes. A MEDLINE (PubMED) database search identified potential articles for inclusion using the search strategy: (dental implants OR oral implants) AND (diabetes OR diabetic). Inclusion in this review required longitudinal assessments including at least 10 patients, with included articles assessed relative to documentation of glycemic status for patients.

RESULTS

Although the initial search identified 129 publications, this was reduced to 16, for inclusion. Reported implant failure rates for diabetic patients ranged from 0% to 14.3%. The identification and reporting of glycemic control was insufficient or lacking in 13 of the 16 studies with 11 of these enrolling only patients deemed as having acceptable glycemic control, limiting interpretation of findings relative to glycemic control. Three of the 16 studies having interpretable information on glycemic control failed to demonstrate a significant relationship between glycemic control and implant failure, with failure rates ranging from 0% to 2.9%.

CONCLUSIONS

Clinical evidence is lacking for the association of glycemic control with implant failure while support is emerging for implant therapy in diabetes patients with appropriate accommodations for delays in implant integration based on glycemic control. The role for implants to improve oral function in diabetes management and the effects of hyperglycemia on implant integration remain to be determined.

Implant overdentures and nutrition: a randomized controlled trial

We conducted a randomized clinical trial to determine whether providing simple mandibular implant overdentures (IODs) to elderly individuals would give them a significantly better nutritional profile than those who receive complete dentures (CDs). Two hundred fifty-five edentate patients > 65 yrs were randomly assigned to receive maxillary CDs and mandibular IODs (n = 128) or CDs (n = 127). Six-month and one-year post-treatment outcomes were blood plasma levels of homocysteine (tHcy), vitamin B12, vitamin B6, albumin, serum folate, and C-reactive protein concentrations, as well as dietary intake. The association between treatment and tHcy levels was not statistically significant. A decline of folate from baseline values in both study groups, as well as those of vitamins B6 and B12 and albumin, was observed. Significant between-group differences were detected in food preparation and in the individuals' ability to chew a variety of foods. This study suggests that implant overdentures do not have a more positive effect on the nutritional state of elderly edentate individuals at 6 and 12 mos post-treatment than new complete dentures. However, those wearing IODs are significantly more likely to take in their nutrients through fresh, whole fruits and vegetables.

The influence of mandibular implant-retained overdentures in masticatory efficiency

OBJECTIVE

To evaluate the masticatory efficiency of patients rehabilitated with conventional dentures (CDs) or implant-retained mandibular overdentures.

BACKGROUND

Despite the evident benefits of implants on mastication as assessed by subjective patient-based outcomes, the extent of implant overdenture treatment effect on food comminution is not well established.

MATERIALS AND METHODS

A randomised clinical trial was carried out with 29 completely edentulous patients divided into two groups. The first group was rehabilitated with a mandibular overdenture retained by two splinted implants with bar-clip system, while the second group was rehabilitated with a mandibular CD. Both groups also were rehabilitated with maxillary CDs. Masticatory efficiency and patient satisfaction were assessed 3 months after denture insertion. Masticatory efficiency was evaluated through the colorimetric method with the beads as the artificial test-food. Comparisons for masticatory efficiency and patient satisfaction were performed using Student's t-test (α = 0.05).

RESULTS

No significant statistical difference was found for masticatory efficiency (p = 0.198). Patient overall satisfaction was significantly higher for the mandibular overdenture (p < 0.001). In addition, mandibular overdenture patients were significantly more satisfied with chewing experience (p < 0.05) and retention of the lower denture (p < 0.005).

CONCLUSION

The results of this study suggest that mandibular overdenture significantly improves chewing experience, although limited effect on masticatory efficiency has been observed.

Immediate loading of mandibular overdentures supported by unsplinted direct laser metal-forming implants: results from a 1-year prospective study

BACKGROUND

At present, only some studies have dealt with immediate loading of unsplinted implants supporting mandibular overdentures. The aim of this prospective study is to evaluate treatment outcomes of mandibular overdentures supported by four one-piece, unsplinted, immediately loaded, direct laser metal-forming (DLMF) implants by assessing implant survival rate, implant success, marginal bone loss, and prosthetic complications.

METHODS

A total of 96 one-piece DLMF implants were inserted in the edentulous mandible of 24 patients. Four implants were placed in each edentulous mandible. Immediately after implant placement, a mandibular overdenture was connected to the implants. At 1-year follow-up, clinical, radiographic, and prosthetic parameters were assessed. Success criteria included absence of pain, suppuration, and implant mobility; absence of continuous peri-implant radiolucency; and distance between the implant shoulder and the first visible bone contact <1.5 mm.

RESULTS

After a 1-year loading time, the overall implant survival rate was 98.9%, with only one implant lost. Among the surviving 95 implants, two did not fulfill the success criteria; therefore, the implant success rate was 97.8%. The mean distance between the implant shoulder and the first visible bone contact was 0.28 ± 0.30 mm (95% confidence interval, 0.24 to 0.32). Some prosthetic complications were reported.

CONCLUSION

Based on the present results and within the limits of this study, the immediate loading of four unsplinted DLMF implants by means of ball attachment-supported mandibular overdentures seems to represent a safe and successful procedure.

Study of Biomechanics of Porous Coated Root Form Implant Using Overdenture Attachment: A 3D FEA

The purpose of this article is to do a three-dimensional finite element stress analysis, in relation to root form implant supported by overdenture attachment, during axial and non-axial loading. Two porous coated Titanium-aluminum-vanadium (Ti-6Al-4V) implants with overdenture abutment were embedded in both simple and 3D model of interforaminal region of mandible. The material properties of tissue ingrowth bonded interface were calculated considering Iso-Strain condition. The masticatory forces: axial load of 35 N, a horizontal load of 10 N, and an oblique load of 120 N, was applied for the two qualities of cancellous bone. It implied that porous topography of the implant led to optimal stress transfer at the tissue ingrowth bonded interface and insignificant punching stress at the apex than a smooth surface implant. The inferior bone quality was deformed even under physiologic loads and showed wider stress pattern. Simulated implant abutment to implant bone interface stress may be significantly affected by the quality of the bone and the surface topography of the implant. The interface is affected to a lesser extent by the prosthetic material properties. Threedimensional anatomical model was more close to reality than the geometry of much simpler altered models.

Overdenture with immediate load: mastication and nutrition

Lower conventional complete dentures were converted to overdentures retained by two implants with an immediately loaded bar-clip system (n 16). The masticatory performance test was carried out using 'Optocal' after forty chewing strokes. Nutritional condition was evaluated by means of a Mini-Nutritional-Assessment questionnaire. No individual was classified as malnourished. The masticatory performance test demonstrated a statistically significant difference before conversion (baseline) and 3 and 6 months after conversion of the lower conventional complete denture to an implant-retained overdenture (paired-samples t test; P < 0·05). A statistically significant difference before and after 6 months of conversion for nutritional condition (Wilcoxon test; P < 0·05) was also observed. The association between masticatory performance and nutritional assessment demonstrated that a statistically significant difference between masticatory performance of the subgroups classified at baseline as nourished (22·43 %) and those at risk of malnutrition (3·9 %) was only evidenced before conversion (P = 0·006). After the conversion from a lower conventional complete denture to an implant-retained overdenture, at 3 months, the risk of malnutrition and nourished at baseline did not present significant differences in masticatory performance. Nonetheless, the mean masticatory performance potential was 19·86 and 31·98 % for subgroups classified at baseline as at risk of malnutrition and nourished, respectively (P = 0·187). The results before conversion were less favourable for masticatory performance and nutritional condition. The increased retention of the mandibular prosthesis allowed improvement in masticatory performance and nutritional condition.

The impact of dietary advice on edentulous adults' denture satisfaction and oral health-related quality of life 6 months after intervention

OBJECTIVE

The aim of this study was to compare the impact of customised dietary advice on patients' satisfaction with their dentures and oral health-related quality of life (OHRQoL) in patients wearing implant-supported mandibular overdentures (IOD) or conventional dentures (CD).

MATERIALS AND METHODS

In this prospective cohort study, 28 IOD (two implant-retained mandibular overdenture) and 26 CD patients completed a denture satisfaction scale and the 20-item oral health impact profile (OHIP-20) before and 6 months following provision of customised dietary advice.

RESULTS

At 6 months following provision of individualised dietary advice, the IOD group showed significantly greater satisfaction than the conventional group for denture comfort (80.6, + or - 15.6, vs. 68.7 + or - 15.6 P=0.001), stability (75.8 + or - 15.9 vs. 59.5 + or - 30.4, P=0.002), and perceived chewing ability (79 + or - 30.4 vs. 59.5 + or - 30.4, P=0.027) + or - when adjusted for baseline scores. Before delivery of the dietary advice there were no significant differences between groups for Satisfaction or OHIP scores. No difference in OHRQoL was seen between groups.

CONCLUSIONS

The delivery of customised dietary advice to edentulous patients impacts differently on their satisfaction with denture comfort, stability and chewing ability depending on the nature of their prosthesis. This re-evaluation of satisfaction occurs when edentulous patients challenge themselves to consume more fruits, vegetables and fibre-rich foods. The IOD group reported an increased level of satisfaction and perceived chewing ability whereas it appeared that CD wearers may have had their awareness of the shortcomings of this sort of prosthesis reawakened.

Impact of implant support for mandibular dentures on satisfaction, oral and general health-related quality of life: a meta-analysis of randomized-controlled trials

OBJECTIVES

The aim of this study was to examine systematically the data published on the efficacy of mandibular implant-retained overdentures from the patient's perspective.

MATERIAL AND METHODS

Medline, Embase, The Cochrane Central Register of Controlled Trials and The Cochrane Systematic Reviews Database were searched and complemented by hand searching. All randomized-controlled trials published in English or French up to April 2007 were included, in which conventional dentures and mandibular implant overdentures in adult edentulous individuals were compared. The outcomes of interest were patient satisfaction, oral and general health-related quality of life. Random effects models were used to pool the effect sizes (ES) of all included studies.

RESULTS

Ten publications of seven randomized-controlled trials were identified and eight were included in the meta-analysis. When compared with mandibular conventional dentures, implant overdentures were rated to be more satisfactory at a clinically relevant level [pooled ES 0.80, z=3.56, 95% confidence intervals (CI) 0.36-1.24, P=0.0004], but a statistical heterogeneity was found (chi(2)=31.63, df=5, P<0.00001, I(2)=84%). The pooled ES for oral health quality of life was -0.41 (z=1.31, 95% CI, -1.02 to 0.20; P=0.19, chi(2)=11.53, df=2, P<0.003, I(2)=83%). There was a lack of evidence to show the impact of mandibular implant overdenture on perceived general health.

CONCLUSIONS

Our findings suggest that, although mandibular implant-retained overdentures may be more satisfying for edentulous patients than new conventional dentures, the magnitude of the effect is still uncertain. There is a need for additional evidence including cost-effectiveness analyses on the impact of mandibular implant overdentures and conventional dentures.

Nutritional and anthropometric analysis of edentulous patients wearing implant overdentures or conventional dentures

As masticatory efficiency diminishes drastically in edentulous patients, several researchers have studied over the past two decades how dietary intake varies when different types of oral rehabilitation are provided. Since the use of implants to support prostheses in edentulous mandibles has been shown to significantly improve masticatory performance, the question remains as to whether this improvement will influence the nutritional status. The purose of this study was to evaluate the nutritional status of edentulous patients who randomly received either a mandibular conventional denture (CD) or an implant-supported overdenture (IP) 1 year previously. Weight, height, body composition and handgrip strength measurements were collected for analysis. Blood tests were performed to measure plasma parameters of diet intake. Participants responded to a Food Frequency Questionnaire and a Masticatory Function Questionnaire. Fifty-three people participated (58% men, 42% women; mean age = 53). Body composition indicators as well as plasma parameters were generally within normal range, and no statistically significant difference (p>0.05) was found between the groups. Patients in the CD group had significantly lower ratings for items regarding difficulty in chewing (p<0.05), but no significant difference was found for dietary intake (p>0.05). Although the CD wearers reported having more difficulty in chewing hard foods, both groups appeared to have a similar nutritional status.

Researching the impact of oral health on diet and nutritional status: methodological issues

OBJECTIVES

Assessment of the impact of dental function on diet and nutritional status requires robust methodologies and a standardised approach to increase accuracy of results and to facilitate cross study comparisons. The objectives of this paper are: to report the outcomes of a consensus workshop that critically reviewed publications reporting on dietary methodologies in relation to the impact of oral health on nutrition; to highlight future directions for research and; to make recommendations for appropriate use of methodologies for future research.

DATA

Data relevant to nutrition and dental status published from 1980 to 2005 in English were presented at the consensus workshop for discussion and appraisal.

SOURCES

Relevant papers were retrieved through PubMed. Relevant texts were obtained from the library at Newcastle University, UK.

STUDY SELECTION

A purposive sample of original articles that illustrated the application of a range of nutritional methodologies to the study of oral health impacts was identified. Original flagship texts on nutritional methodologies were reviewed.

CONCLUSIONS

Numerous studies have shown an association between loss of teeth and inferior diet. Further research is required to elucidate the impact of novel approaches to prosthetic rehabilitation and the impact of contemporaneous dietary and dental intervention on diet, nutritional status, disease progression and quality of life. The recommendation of the consensus workshop was that future studies should adopt a comprehensive approach to the assessment of nutrition that encompasses measurement of diet, body composition, biochemical indices of intake and levels of nutrients, and functional biomarkers of disease.

Perceived chewing ability and intake of fruit and vegetables

Edentulous individuals have reduced chewing ability and lower fruit and vegetable consumption compared with dentate individuals. It has been suggested that the two are causally related. However, psychosocial factors such as attitude, self-identity, and knowledge of recommendations are predictive of intake in non-edentulous persons. The aims of this study were to: determine if perceived chewing ability was predictive of fruit and vegetable intake; explore the predictive ability of knowledge, attitude, and self-identity; and compare intake between edentulous and dentate individuals. Full denture-wearing (N = 79) and dentate persons (N = 52) completed a three-day food diary. Perceived chewing ability, sociodemographic, and psychosocial factors were assessed via self-administered questionnaire. The dentate persons consumed significantly more fruit and vegetables, but differences were not significant when juices were excluded. Perceived chewing ability explained approximately 4% variance in intake. Attitude, self-identity, and knowledge explained a further approximately 20%. If the diet of denture-wearers is to be improved, psychosocial factors, as well as perceived chewing ability, must be addressed.

Influence of denture improvement on the nutritional status and quality of life of geriatric patients

Recent research suggests that there is a correlation between nutrition, oral health, dietary habits, patients' satisfaction and their socio-economic status. However, the dependent and independent variables have remained unclear.

OBJECTIVE

This exploratory interventional study aimed to identify the impact of denture improvement on the nutritional status as well as the oral health-related quality of life in geriatric patients.

MATERIALS AND METHODS

Forty-seven patients who were capable of feeding themselves (minimum age: 60 years) and with dentures requiring repair or replacement were selected from a random sample of 100 residents of two nursing homes. Before and 6 months after the dentures were optimised a Mini Nutritional Assessment (MNA) and a masticatory function test were carried out. Nutritional markers (pre-albumin, serum albumin, zinc) were determined and an OHIP-G14 (Oral Health Impact Profile, German version) was recorded in order to determine the effect of the optimised oral situation on the patient's nutritional status and oral health-related quality of life.

RESULTS

Despite the highly significant improvement in masticatory ability after the optimisation of the dentures, no general improvement regarding the nutritional status was observed since the albumin, zinc and MNA values remained unchanged and pre-albumin even decreased.

CONCLUSION

Since masticatory ability and masticatory efficiency are not the only factors affecting this, prosthetic measures alone apparently cannot effect a lasting improvement in nutritional status as masticatory ability and masticatory efficiency are not the only factors of influence. Nutrition is not only a matter of masticatory function, but also depends on other influencing factors (e.g. habits, taste and cultural customs as well as financial and organisational aspects).

Implant overdentures for edentulous elders: study of patient preference

BACKGROUND

Studies show that elders wearing implant overdentures have improved nutrition and quality of life. However, upfront costs of this therapy are high, and the income of elderly edentulous populations is low.

OBJECTIVES

This study was designed (i) to measure the preferences of edentulous patients for mandibular two-implant overdentures using Willingness-To-Pay (WTP) and Willingness-To-Accept (WTA), (ii) to assess the effect of long-term financing on WTP and (iii) to assess the desired role of health care plans in financing dental prostheses.

METHODS

Edentulous elders (68-79 years; n = 36) wearing maxillary dentures and either a mandibular conventional denture (CD, n = 13) or a two-implant overdenture with ball attachments (IOD, n = 23) participated in this study. All had received their prostheses 2 years previously, as part of a randomised clinical trial. A three-part questionnaire was completed during a 20-min interview with a trained researcher.

RESULTS

Forty-six per cent (6/13) of the CD wearers and 70% (16/23) of the IOD wearers were willing to pay three times more than the current cost of conventional dentures for implant prostheses. These percentages were increased to 77% (CD) and 96% (IOD) if participants could pay for implant overdentures in monthly instalments. Eighty-six per cent (31/36) of all participants in both groups (21/23 IOD; 10/13 CD) thought that the government should cover at least some of the cost of implant overdentures.

CONCLUSIONS

This study shows that, the majority of elderly edentate individuals who have not experienced mandibular two-implant overdenture therapy are willing to pay the cost, particularly when payment can be made in monthly instalments.

Position of the American Dietetic Association: Oral Health and Nutrition

It is the position of the American Dietetic Association that nutrition is an integral component of oral health. The American Dietetic Association supports the integration of oral health with nutrition services, education, and research. Collaboration between dietetics and dental professionals is recommended for oral health promotion and disease prevention and intervention. Scientific and epidemiological data suggest a lifelong synergy between nutrition and the integrity of the oral cavity in health and disease. Oral health and nutrition have a synergistic bidirectional relationship. Oral infectious diseases, as well as acute, chronic, and terminal systemic diseases with oral manifestations, impact the functional ability to eat as well as diet and nutrition status. Likewise, nutrition and diet may affect the development and integrity of the oral cavity as well as the progression of oral diseases. As we advance in our discoveries of the links between oral and nutrition health, practitioners of both disciplines must learn to provide screening, baseline education, and referral to each other as part of comprehensive client/patient care. Dietetics practice requires registered dietitians to provide medical nutrition therapy that incorporates a person's total health needs, including oral health. Inclusion of both didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in both dental and dietetic education programs. Collaborative endeavors between dietetics and dentistry in research, education, and delineation of health provider practice roles are needed to ensure comprehensive health care. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit continued, detailed delineation.

Is the goal of mastication reached in young dentates, aged dentates and aged denture wearers?

The objective of the present study was to assess the impact of age and dentition status on masticatory function. A three-arm case-control study was performed. Group 1 (n 14) was composed of young fully dentate subjects (age 35.6 +/- 10.6 years), group 2 (n 14) of aged fully dentate subjects (age 68.8 +/- 7.0 years) and group 3 (n 14) of aged full denture wearers (age 68.1 +/- 7.2 years). Mastication adaptation was assessed in the course of chewing groundnuts and carrots to swallowing threshold. Particle size distribution of the chewed food, electromyographic (EMG) activity of the masseter and temporalis muscles during chewing, and resting and stimulated whole saliva rates were measured. Aged dentate subjects used significantly more chewing strokes to reach swallowing threshold than younger dentate subjects (P < 0.05), with increased particle size reduction, longer chewing sequence duration (P < 0.05) and greater total EMG activity (P < 0.05) for both groundnuts and carrots. In addition, aged denture wearers made significantly more chewing strokes than aged dentate subjects (P < 0.001) to reach swallowing threshold for groundnuts. Particle size reduction at time of swallowing was significantly poorer for denture wearers than for their aged dentate counterparts, despite an increase in chewing strokes, sequence duration and EMG activity per sequence. Masticatory function was thus adapted to ageing, but was impaired in denture wearers, who failed to adapt fully to their deficient masticatory apparatus.

Effect of loading time on the success of complete mandibular titanium implant retained overdentures: a systematic review

OBJECTIVES

The aim of this review was to compare conventional against early/immediate loading protocols of implant-retained overdentures (IOD) in the edentulous mandible.

MATERIAL AND METHODS

Medline search via Ovid to extract prospective comparative studies on trials comparing the effect of timing of loading initiation on the success of mandibular IOD. The outcome of major interest was marginal bone loss. Probing depth, plaque, bleeding index and mobility were also assessed. Indices at 12 and 24 months were compared and changes assessed. Outcomes were entered into RevMan (version 4.2.5) for meta-analysis.

RESULTS

Of 239 articles, only nine trials fulfilled the criteria and involved 30 immediate, 71 early, 77 one-stage conventional, and 66 two-stage conventional subjects. Three immediate loading trials showed an increase in the amount of marginal bone loss over time, while the majority of early and conventionally loaded implants exhibited a decrease in the amount of bone loss in the second year compared with the first 12-month period. Probing depth at 24 months showed a significant difference between early and conventional loading; SMD 0.5 (95% confidence interval 0.03, 0.97). No other statistically significant differences were found between either immediate or early and conventional loading for any indices.

CONCLUSIONS

No deleterious effects up to 24 months have been shown from immediate or early loading. Conventional loading after a 3-month healing period has not been proven to be the only acceptable protocol for mandibular IOD, but further long-term studies are needed to confirm this.

How do patients perceive the benefit of reconstructive dentistry with regard to oral health-related quality of life and patient satisfaction? A systematic review

BACKGROUND

Reconstructive dentistry encompasses an enormous range of treatment modalities from the restoration of single teeth to the reconstruction of the whole dentoalveolar complex in edentulous patients. Some treatment modalities have been assessed in terms of quality-of-life (QoL) outcomes and satisfaction

OBJECTIVES

The aim of the present investigation was to search and review studies published between 1996 and 2006 in which the impact of the treatment was measured in terms of QoL outcome, ideally, oral health-related quality of life (OHRQoL). Patient satisfaction was also accepted as an outcome.

MATERIALS AND METHODS

The primary search engine used was NICB PubMed based on MeSH headings. Hand searching of the cited references in the included papers identified a number of additional studies. The primary focus of the search was to link treatment to QoL outcomes.

RESULTS

The majority of included studies involved the treatment of edentulous patients, particularly the mandible. The preponderance of the studies comparing conventional dentures (CDs) and implant-supported overdentures (IODs) were randomized-controlled trials (N = 18). There was compelling evidence that patients were more satisfied with IODs than CDs. There was strong evidence that OHRQoL can be significantly improved using IODs. Evidence suggesting that one retention system is superior to another needs further clarification. Although high satisfaction ratings have been reported for maxillary implant prostheses, the overall ratings given to the maxillary implant prostheses were not significantly greater than for CDs. There was only sparce information regarding QoL or satisfaction outcomes for the majority of other forms of reconstructive dentistry.

CONCLUSION

Apart from the restoration of the edentulous mandible with IODs or CD, where there is an accumulating body of evidence on the effect of treatment choice, there are many procedures for which there are little or no such data at all. As yet, the entire range of reconstructive treatment has witnessed insufficient investigations relating treatment to its effect on QoL or satisfaction. This is an area that needs to be expanded as a way of quantifying the effect of treatment choices.

Metabolic syndrome: pathogenesis, medical care and dental implications

BACKGROUND

The dental literature contains little information about metabolic syndrome (MetS) and its dental implications.

TYPES OF STUDIES REVIEWED

The authors conducted a MEDLINE search for the period 2000 through 2005, using the term "metabolic syndrome" to define its pathophysiology, medical treatment and dental implications.

RESULTS

MetS is the co-occurrence of abdominal obesity, hyper-triglyceridemia, reduced high-density lipoprotein cholesterol levels, hypertension and impaired fasting glucose, which results from consumption of a high-calorie diet and decreased levels of physical activity superimposed on the appropriate genetic setting. Components of MetS synergistically promote the development of atherosclerosis, resulting in myocardial infarction and stroke.

CLINICAL IMPLICATIONS

Deteriorating oral health status is associated with worsening of the atherogenic profile. Tooth loss often results in chewing difficulties because of inadequate occlusive surfaces and may lead to alterations in food selection and dietary quality. This, in turn, adversely affects body composition and nutritional status, both of which are related to vascular health. Dentists should develop treatment plans that preserve and restore the dentition, thus ensuring maximum masticatory efficiency and affording patients the optimum opportunity to consume food that will not foster atherogenesis.

Can general dentists produce successful implant overdentures with minimal training?

OBJECTIVES

This study was carried out to determine whether inexperienced dentists can provide two-implant overdentures that are as satisfactory and of the same cost as those provided by experienced prosthodontists.

METHODS

Edentulous elders were enrolled in a randomized controlled clinical trial to compare the effects of mandibular conventional and two-implant overdentures on nutrition. They were randomly assigned to groups that were treated by either an experienced prosthodontist or by a newly-graduated dentist with minimal training in implant treatment. Data for this study were obtained during the treatment of the first 140 subjects enrolled. The change in patient ratings of satisfaction after treatment, laboratory costs and the number of unscheduled visits up to 6 months following prosthesis delivery were compared.

RESULTS

Satisfaction was significantly higher with implant overdentures than with conventional dentures, but there were no differences in scores for either prosthesis between the groups treated by experienced specialists or new dentists. Furthermore, six of the seven inexperienced dentists reported that they found the mandibular two-implant overdenture easier to provide than the conventional denture.

CONCLUSIONS

The results of this study suggest that general dentists can provide successful mandibular two-implant overdentures with minimal training.

Treatment planning of the edentulous mandible

Edentulism can be a debilitating handicap. Zarb described endentulous individuals who could not function as 'denture cripples'.(1) Most difficulty with complete denture prostheses arises from the inability to function with the mandibular prostheses. Factors that adversely affect successful use of a complete denture on the mandible include: 1) the mobility of the floor of the mouth, 2) thin mucosa lining the alveolar ridge, 3) reduced support area and 4) the motion of the mandible (Figs 1,2). These factors alone can explain the difficulty of wearing a denture on the mandibular arch compared to the maxillary arch. The maxilla exhibits much less mobility on the borders of the denture than the mandible, moreover having a stable palate with thick fibrous tissues available to support the prostheses and resist occlusal forces. These differences explain most of the reasons why patients experience difficulty with using a complete denture on the mandibular arch compared to the maxillary arch.

Evidence-based decision-making: implants versus natural teeth

The clinician is increasingly confronted with the dilemma of whether to use implants or so-called "traditional" dental interventions. Given the high predictability of implants, their use should be considered routine. The survival and success rates reported by many investigators often exceed the success rates of some forms of heroic treatment. Findings from well-designed trials must be used to guide clinical decision-making. In this article, the authors review studies of outcomes related to one particular implant system and compare these results to those reported for various forms of endodontic therapy and tissue-supported mandibular complete dentures. The results suggest that implant restorations of the system in question have a level of predictability equal to or greater than that for traditional dental treatment.

Measuring chewing ability in randomized controlled trials with edentulous populations wearing implant prostheses*

In this article, the authors review methods commonly used to measure the masticatory ability of patients wearing conventional and implant prostheses. Measurement approaches are viewed in two broad categories: laboratory based and patient based. The laboratory based measures discussed are mastication time, particle size, force measurements, patterns of jaw movement and electromyographic (EMG) bursts and total EMG activity. Patient based measures include satisfaction and chewing difficulty. Oral health-related quality of life measures and diet/nutrition variables are briefly mentioned. Patient-based outcomes are recommended as the most appropriate variables of masticatory efficiency.

Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients

Nutrition is an important determinant of health in persons over the age of 65. Malnutrition in the elderly is often underdiagnosed. Careful nutritional assessment is necessary for both the successful diagnosis and development of comprehensive treatment plans for malnutrition in this population. The purpose of this article is to provide clinicians with an educational overview of this essential but often underecognized aspect of geriatric assessment. This article will review some common issues in nutrition for the elderly in both hospital and community settings. The complexity and impact of multiple comorbidities on the successful nutritional assessment of elderly patients is highlighted by using case scenarios to discuss nutritional issues common to elderly patients and nutritional assessment tools. Three case studies provide some context for an overview of these issues, which include the physiology of aging, weight loss, protein undernutrition, impaired cognition, malnutrition during hospitalization, screening procedures, and general dietary recommendations for patients 65 years of age and older.

The relationship between dietary intake and the number of teeth in elderly Japanese subjects

OBJECTIVE

This study used a precise weighing method to assess whether tooth loss was related to nutrient intake in elderly Japanese subjects.

MATERIAL AND METHODS

Fifty-seven subjects aged 74 years were randomly selected from a longitudinal interdisciplinary study of ageing. Complete 3-day food intake data were obtained by a precise weighing method. The dietary intakes of energy and nutrients were calculated based on the Standard Tables of Food Composition in Japan (5th ed.). A clinical evaluation of the number of teeth present was carried out. Multiple regression standardised coefficients for each nutrient was estimated based on a continuous scale adjusted for gender, smoking habits, and educational level. After dividing the subjects into two groups according to the number of teeth present (0-19, 20+), the difference in the intake of nutrients and the amount of food consumed per day was evaluated.

RESULTS

The number of teeth present had a significant relationship with the intake of several nutrients. In particular, total protein, animal protein, sodium, vitamin D, vitamin B1, vitamin B6, niacin, and pantothenic acid were significantly associated with the number of teeth present and with the two groups (0-19, 20+). The intake of vegetables and fish, shellfish, and their products was significantly lower among subjects with fewer teeth.

CONCLUSION

This study suggests that there was a significant relationship between nutrient intake, such as minerals and vitamins from food, and tooth loss.

Mundgesundheit, Zahnstatus und Ernährung im Alter

The loss of natural teeth impairs essentially the chewing function and can only partly be restored by the insertion of dental prostheses. Equally, xerostomia and dysphagia may aggravate the nutritional intake in older adults. Often denture wearers do subjectively not notice the adjustment of their food choice and the employment of special preparation techniques. Finally the dental state influences the nutritional intake. A reduced number of teeth correlates with the intake of less calories, proteins, fat, non-starch polysaccharides and vitamins. Often missing calories are compensated by an increased consumption of sugar and fat. Especially edentulous persons with a low level of education choose a diet which is rich in fat and sugar. Further the daily intake of fruit and vegetables diminishes along with fewer occlusal contacts in posterior teeth. The restoration of the chewing function by dental intervention does not lead to an improvement of the nutritional intake by itself and should therefore always be complemented by nutritional advice.

The relationship between oral health and nutrition in older people

The oral health of older people is changing with reducing numbers of people relying on complete dentures for function, and retaining some natural teeth. Despite this there are substantial numbers of older people whose ability to chew foods is compromised by their oral health status, either because they have few or no natural teeth. This alteration results in individuals selecting a diet that they can chew in comfort. Such diets are low in fruits and vegetables intake with associated reduction in both non-starch polysaccharide and micronutrient intakes. There is also a trend for reduced dietary intake overall. Salivary flow and function may have an impact in relation to the ability to chew and swallow. Whilst there are few differences in salivary function in fit healthy unmedicated subjects, disease resulting in reduced salivary flow and particularly polypharmacy, with xerostomia as a side effect, are likely to have a role in older people. This paper explores the relationships between oral health status and food's choice and discusses the potential consequences for the individual of such dietary change.

The masticatory handicap of wearing removable dentures in elderly men

OBJECTIVE

This study aimed at describing the masticatory handicap of wearing removable dentures measured by some masticatory tests and the intake of hard and soft foods.

MATERIALS AND METHODS

The subjects were participants in a comprehensive health examination of 67-68-year-old men living in Malmö, Sweden. Four hundred eighty-three men took part in a clinical oral examination which recorded the number of teeth and removable dentures. One hundred and one had complete dentures in both jaws and 131 had removable partial dentures in different combinations. Masticatory tests used almonds to record the number of stokes to the first swallow, and two-coloured chewing gums for recording bolus kneading and shaping. A nutritionist paid a home visit to assess dietary habits including the consumption of hard and soft foods. The data could be split into groups of different tooth and denture situations which were large enough to enable statistical analysis to be carried out. The results of a regression analysis of the group with different numbers of natural teeth (NT) and no removable dentures could be used as a reference for correlation with the masticatory capacity of removable denture wearers.

RESULTS

Number of strokes to the first swallow revealed no masticatory limitations of wearing removable dentures, while chewing gum colour-mixing and shaping revealed more differentiated impairments equivalent to the function of five to 16 teeth in a remaining natural dentition. Hard food intake for the removable denture groups was comparable to 17-19 NT. Soft food intake was not influenced by denture wearing. In a ranking of oral conditions, those with more than 24 NT had the highest test values for all tests, and those with complete sets of dentures the lowest except for the number of strokes to the first swallow of an almond.

CONCLUSION

Removable denture wearing can be regarded as a handicap when measured with objective masticatory tests using chewing gum and the intake of hard foods. The number of chewing strokes to the first swallow of an almond and the intake of soft foods is not affected by the wearing of removable dentures.

Mandibular two-implant telescopic overdentures. 10-year clinical and radiographical results

To stabilize mandibular overdentures in edentulous patients, various connector types which can be attached to between two and four implants placed in the anterior mandible are possible. Treatment using non-rigid telescopic connectors on two interforaminal implants for overdenture stabilization began in 1989. The objective of this study is to investigate soft- and hard-tissue conditions as well as prosthesis function after a period of 10 years. This also involved an evaluation of correlations between radiographic and clinical parameters. Twenty-three subjects with 46 interforaminal implants (ITI solid screw implants, 12 mm in length, 4.1 mm in diameter; 10.4 years in situ, range, 8-12.8 years) were investigated. Modified plaque index (mPI), sulcus fluid flow rate (SFFR), modified sulcus bleeding index (mBI), probing depth (PD), distance from implant crown margin to the coronal border of the peri-implant mucosa (DIM), attachment level (AL), width of keratinized mucosa (KM), Periotest values (PTVs) and prosthesis function were evaluated. In the radiographic evaluation, the distance between implant shoulder and first crestal bone-implant contact (DIB) in mm and the horizontal bone loss (HBL) in mm were measured. The relatively high mPI scores (mean, 0.82; score, 0 in 44.4%; SD, 0.83) did not result in increased SFFR scores (mean, 12; min, 3, max, 38; SD, 7.43) or higher mBI scores (mean, 0.35; score, 0 in 70.8%; SD, 0.59), which was commensurate with healthy peri-implant mucosa. A mean PD value of 2.15 mm (min, 1 mm; max, 5 mm; SD, 0.96) and a mean DIM value of 0.28 mm (min, 0 mm; max, 2 mm; SD, 0.52) were measured. The implants were stable, showing a mean Periotest value of -1.91 (max, 02, min, -6; SD, 1.76). A mean DIB of 3.19+/-0.95 mm (range, 1.3-5.16 mm) and a mean HBL of 1.6+/-1.52 mm (range, 0.28-8.33 mm) were calculated. A correlation was found between DIB and the parameters SFFR (P=0.060), DIM (P=0.042), AL (P=0.050) and especially PTV (P<0.01), leading to the assumption that these clinical parameters may be useful indicators of peri-implant bone loss. The results of the 10-year follow-up examination show that non-rigid telescopic connectors with two interforaminal implants for overdenture stabilization appear to be an efficient and effective long-term treatment modality in severely resorbed edentulous mandibles. Particularly in geriatric patient treatment this concept may provide advantages in terms of handling, cleaning and long-term satisfaction.

Dental endosseous implants

BACKGROUND

The ADA Council on Scientific Affairs has developed an updated report on endosseous implants to aid dental professionals in considering and incorporating practical applications of implantation therapy in general practice.

OVERVIEW

This report addresses the demonstrated high success rates of multiple implant designs in various clinical situations, the factors contributing to elevated risk of implant failure and implantation therapy as a comprehensive process of patient care. The Council also provides a list of products available to the profession that have received the ADA Seal of Acceptance.

CONCLUSIONS AND PRACTICE IMPLICATIONS

The Council recommends that practitioners use implantation therapies and systems judiciously in accordance with the current best evidence. The Council also urges evaluators to use common and consistent criteria for reporting the outcomes assessment in clinical studies of various implant treatments.