Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 892899

Subjective values of different treatments for missing molars in older Japanese

K. IKEBE, T. HAZEYAMA, R. KAGAWA, K. MATSUDA & Y. MAEDA
of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry, Yamadaoka, Suita, Osaka, Japan Department

SUMMARY The purpose of this study was to determine how elderly Japanese people subjectively value treatment options for missing molars. Subjects were 528 independently community-dwelling elderly people. They were presented with photographs and descriptions of the process and expected outcomes of ve possible treatment options: cantilever xed dental prosthesis (FDP); resin or metal removable partial denture prosthesis (RPDP); implant-supported xed prosthesis; and no replacement (shortened dental arch: SDA) for missing lower bilateral rst and second molars. The participants lled in the questionnaire on subjective importance for treatment and indicated on a visual analogue scale how they valued the treatment (utility value: UV). Values were analysed by Mann Whitney U-tests and multiple logistic regression analyses. Overall, the UVs for the FDP and the metal RPDP were the highest, and the UV for the SDA was the lowest. With respect to subjective importance, chewing ability and no pain during function were

signicantly selected more frequently. Multiple logistic regression analyses showed that the UV for the resin RPDP had signicant positive associations with denture wearers and low treatment cost, whereas the implant had signicant negative associations with denture wearers and older age. The SDA had signicant positive associations with men and low treatment cost and a negative association with appearance. In conclusion, these elderly Japanese preferred cantilever FDPs and metal RPDPs to implants and no replacement. It suggests that the SDA as an oral health goal can be questionable from the patients point of view, even if it is biologically correct. KEYWORDS: treatment options, missing molars, removable partial denture prosthesis, cantilever xed dental prosthesis, shortened dental arch, implant, subjective value, visual analogue scale Accepted for publication 2 June 2010

Introduction
In treatment decisions, both the health care professionals and the patients play an important role. The decision of whether and how to treat a patient depends upon the balance among the perceived advantages, such as selfimage, aesthetics or enjoyment of eating, as well as the disadvantages, such as invasiveness, treatment period, possible side effects or treatment cost. It is now generally accepted, especially for chronic medical conditions, that a patient-oriented system for clinical decision-making leads to greater success than a doc 2010 Blackwell Publishing Ltd

tor-oriented system (1, 2). Thus, it is believed that the patients values and preferences should take a central role in the clinical decision-making process (3). Utility is a general concept for measuring the value individuals attach to the consequences of various courses of action (4). The utility approach is now a viable alternative for investigators to use in measuring health-related quality of life (5). Although the concept of the utility value (UV) and formal methods of incorporating utility measurements into evidencebased practices (6) are widely accepted in medicine, applications to dentistry have been relatively limited.
doi: 10.1111/j.1365-2842.2010.02123.x

SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

This concept is important, especially for prosthodontics, because oral rehabilitation with prostheses aims to enhance quality of life rather than to eradicate disease. Historically, several treatment options for missing molars have been proposed, including a removable partial denture prosthesis (RPDP), a cantilever xed dental prosthesis (FDP) or, recently, an implant-supported prosthesis. The conventional belief that posterior missing teeth should be replaced with a prosthesis as soon as possible has been disputed by several researchers because improvement of oral functions by prostheses is unclear and such prostheses may cause many types of oral diseases (79). There appears to be a trend in favour of the use of the shortened dental arch (SDA) concept or implant-supported restorations instead of conventional RPDPs, given the evidence that the longterm use of RPDP is associated with increased risk of caries and periodontitis and low patient acceptance (10). This suggests that an SDA is an important strategy to avoid over-treatment and side effects of tooth replacement. In addition, some studies in Western countries found that the SDA with 20 teeth is aesthetic, functional and acceptable to patients and remains stable over time (11, 12). However, dietary habit, sense of well-being, economic status and the social security system of each country vary remarkably and signicantly inuence clinical decisions regarding treatments. Additionally, the selection of treatment options by patients is usually inuenced by age, gender, dental status, nancial status and the individuals appreciation of oral health. The purpose of this study was to determine how elderly Japanese people value resin and metal RPDPs, a cantilever FDP, an implant-supported prosthesis or no replacement for missing molars. Additionally, we evaluated the agreed-upon treatment in relation to the subjective factors that were a part of the individuals decision-making process. once a week. This college, which enrols volunteers for a period of 1 year and is supported by the government of Osaka prefecture, is part of the adult education system for those over the age of 60. Total subjects were 528 individuals (237 men and 291 women), and their mean age was 660 years (SD 42). First, participants lled in the self-administered questionnaire that requested information about sociodemographic variables such as age; gender; self-assessed general health; satisfaction with nancial status; educational level; and their present dental status (complete denture, removable partial denture prosthesis or natural dentition). Participants were divided into a removable denture group and a natural dentition (dentate) group, including those with xed prostheses. In this study, a clinical case involving missing bilateral lower rst and second molars (13) was presented to all the participants. All the maxillary teeth and the other mandibular incisors, canines and premolars were assumed to be intact. All participants were interviewed and presented with photographs of ve possible options (Appendix 1). The treatment processes, time periods, conceivable side effects, coverage by National Health Insurance and expected outcomes were explained with wording based on the paper by Nassani et al. (13) and modied in the context of the actual situation in Japan (Appendix 2). The four treatments with prostheses, in addition to the option of no-treatment, were as follows: 1 An acrylic-resin-based RPDP (resin RPDP). 2 A cobaltchromium-based RPDP (metal RPDP). 3 A conventional cantilever FDP (cantilever FDP). 4 An implant-supported FDP (Implant). 5 No treatment: an SDA without replacement (SDA). Only resin RPDPs were coverable by the Japanese National Health Insurance. The cantilever FDP was assumed to use two abutments of the rst and second premolars and replaced one missing molar. To measure the UV (13) of each treatment, participants were asked to indicate on a standardized visual analogue scale how they would rate treatments of their own mouths if they had received each of the treatments. The visual analogue scale was a 100-mm horizontal line with two clear end points. The left end point represented the worst option, which they would not want. On the other end of the line, the right end point represented the perfect option, which they would want. A UV of 0 represented the worst possible treatment, and a UV of 100 represented the best.

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Materials and methods

The study protocol was approved by the Institutional Review Board of the Osaka University Graduate School of Dentistry. All subjects gave written, informed consent prior to participation. The participants in this investigation were community-dwelling, independently living elderly people. They were participants of the Senior Citizens College of Osaka prefecture who voluntarily attended lectures
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Additionally, participants were asked to select three of six values in accordance with what they considered important for the treatment of their missing molars. The six items presented were no pain during function, less invasive to a natural tooth, chewing ability, speaking ability, appearance and low treatment cost. Data analyses were conducted using SPSS Version 140 for Windows*. Because the UVs were not normally distributed, non-parametric tests were used for the statistical analyses. The MannWhitney U-test was used for the comparisons of the UVs of each treatment between the two groups, for example, denture and dentate groups. To compare the UVs of the ve treatment options, the Friedman test was used for statistical analyses. Pairwise comparisons were made using the Wilcoxon test with a Bonferroni correction. P-values of <005 were considered to be statistically signicant. Finally, because the UV is a multifactorial condition, multiple logistic regression analyses were used in tests of the independent variables relationship with the dichotomous dependent variables after controlling for other factors. The dependent variables were the UVs of each treatment option. The participants were dichotomized by splitting at the median of the UVs of each treatment option, such that the higher half was equal to 1 and the lower half was equal to 0. For these analyses, independent variables were age (6069 years and 70+ years), gender (women and men), dental status (dentate and removable denture) and important items for decision-making (unimportant and important). Independent variables were entered into the model by a stepwise method at a signicant level of 005.
100

80

Utility value

60

40

20

0
R PD P al R PD P ev er F pl an t SD A D P

R es in

et

Fig. 1. Average and standard deviation of UVs of all treatment options. Overall, the UV for the cantilever FDP and the metal RPDP were the highest, and the UV for the SDA was the lowest. The UVs were signicantly different between treatment options except between the cantilever FDP and the metal RPDP, according to the Friedman test and pairwise comparisons.

Results
The average UV of all the treatment options for all subjects was 477 350 (SD). Overall, the UVs for the cantilever FDP and the metal RPDP were the highest, and the UV for the SDA was the lowest (Fig. 1). The UVs were signicantly different between treatment options except for between the cantilever FDP and the metal RPDP, according to the Friedman test and the pairwise comparisons. Between any dichotomized groups, such as between men and women or between important and unimportant decision-making items, the rank orders of the UVs were not remarkably different.
*SPSS Inc., Chicago, IL, USA.

With respect to the subjective importance for the replacement of missing molars by the participants, chewing ability (858%) and no pain during function (717%) were signicantly selected more frequently than the other options (the second column in Table 1). The other items were selected by 387279% of the total participants. In bivariate analyses (Table 1), the older group (70 years and over) rated the resin RPDPs signicantly higher and rated implants signicantly lower than the younger group (6069 years). Women rated the SDA signicantly lower than men. Removable denture wearers placed a higher value on RPDPs. In contrast, dentate subjects valued implants and the SDA without replacements higher than the denture wearers. Participants giving importance on low treatment cost rated both resin RPDPs and SDAs signicantly higher and rated implants signicantly lower than did subjects for whom low cost was less important. Also, participants giving importance on appearance rated cantilever FDP signicantly higher and rated resin RPDPs signicantly lower. Participants giving importance on less invasive to a natural tooth rated cantilever FDP signicantly lower than the counterparts. In multiple logistic regression analyses (Table 2), the UV for the resin RPDP had signicant positive associations with individuals wearing dentures and impor 2010 Blackwell Publishing Ltd

C an

til

Im

SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

Table 1. Comparison of the utility value for each treatment option between two groups in relation to age, gender, dental status and important factors for treatment Shortened dental arch P-value Mean SD 253 316 * 263 322 226 298 286 319 227 313 285 335 186 269 238 311 343 335 254 320 249 307 292 321 227 311 256 311 251 320 221 316 268 316 275 341 245 307 ns P-value

895

Resin RPDP % of subjects Mean SD Total 100 Age 6069 807 70+ 193 Gender Male 450 Female 550 Dental status Dentate 615 Removable denture 385 Chewing ability Important 858 Unimportant 142 No pain during function Important 717 Unimportant 283 Low treatment cost Important 387 Unimportant 613 Less-invasive to a natural tooth Important 341 Unimportant 659 Appearance Important 315 Unimportant 685 Speaking ability Important 279 Unimportant 721 521 333 499 336 619 302 550 299 500 357 434 329 643 303 526 336 490 312 513 335 542 328 596 291 474 349 531 327 515 337 441 348 559 319 518 334 522 333 **

Metal RPDP P-value Mean SD 582 311 575 308 608 322 572 286 593 328 549 307 631 314 581 314 592 291 595 306 548 325 590 292 578 322 624 293 561 318 565 329 591 303 549 336 595 300 ns

Cantilever FDP P-value Mean SD 613 310 610 308 642 307 608 297 619 320 606 303 615 327 619 310 570 307 613 311 614 307 620 296 609 318 529 309 657 301 659 294 591 315 633 306 605 311 ns

Implant

P-value Mean SD 419 351 436 348 347 357 411 336 422 363 454 347 360 350 425 356 380 320 411 348 439 361 382 324 442 366 423 351 416 352 462 367 398 342 425 364 416 347

ns

ns

ns

ns

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ns

ns

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ns

ns

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ns, no signicance; FDP, xed dental prosthesis; RPDP, removable partial denture prosthesis. MannWhitney U-test **P<005, *P<001; bold numbers are mean values with a signicant difference.

tance on low treatment cost and a negative association with importance on appearance. The UV for the metal RPDP signicantly associated with individuals wearing dentures, and the UV for the cantilever FDP had a negative association with importance on being less invasive to a natural tooth. The UV for the implants had signicantly negative associations with individuals wearing dentures and older age. The UV for the SDA had signicantly positive associations with men and importance on low treatment cost and a negative association with importance on appearance.

Discussion
Perceptions of health and disease, subjective needs and preferences for treatments vary among patients
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with the same condition. Thus, treatments should also be designed on an individual basis according to the patients needs and demands (14). It is important to recognize how patients of a certain age and of a specic dental state rate various treatment options. Overall, the rank of the UVs of each treatment option was similar between dichotomized groups. Participants placed the highest value on the cantilever FDP, not only in dentate individuals but also in denture wearers; however, individuals who highly rated less invasiveness to the natural teeth valued cantilever FDPs less than did the other individuals. Obviously, oral comfort is more effectively achieved using xed rather than removable restoration (10), which seems to be a reason for the higher preference of the cantilevered FDP.

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Table 2. Logistic regression model for the utility values of each treatment option by a stepwise method Odds ratio 376 058 183 95% Condence interval 249 038 121 567 089 277

Dependent variables Resin RPDP

Independent variables

B 132 )055 060

se 021 022 021

P-value <0001 0013 0004

Dental status (denture) Appearance Low treatment cost Sensitivity: 745; Specicity: 571 Metal RPDP Dental status (denture) Sensitivity: 674; Specicity: 468 Less invasive to a natural tooth Sensitivity: 448; Specicity: 758 Age Dental status (denture) Sensitivity: 529; Specicity: 621 Gender (male) Appearance Low treatment cost Sensitivity: 658; Specicity: 530 SDA Implant Cantilever FDP

060 )093

019

0002

182

124

267

020

<0001

039

026

059

)059 )048 045 )045 046

026 020

0021 0015

055 062

033 042

091 091

020 021 020

0021 0031 0024

156 063 158

108 042 106

233 096 236

Dependent variable: utility value for each treatment; Independent variables: age (6069 years = 0, 70+ years = 1), gender (female = 0, male = 1), dental status (dentate = 0, removable denture = 1) and important items selected (unimportant = 0, important = 1), RPDP, removable partial denture prosthesis; FDP, xed dental prosthesis; SDA, shortened dental arch.

In our previous study (15), most dentists rated cantilevered FDPs lower than implant-supported prostheses because FDPs require a sacrice of healthy enamel and dentine, which goes against the recent minimal intervention concept. In this study, participants were more concerned with chewing ability and the absence of pain during function while being less concerned with the preservation of natural teeth. Because dentists had a professional background in and were more informed about the biological disadvantages of preparing abutment teeth, their preference to their own oral status should be taken into consideration. The minimal intervention concept is expected to be widely accepted by Japanese patients, although it is not yet at this moment. This study also conrmed that RPDPs remain an adequate and economical treatment option. Indeed, removable denture wearers preferred an RPDP as opposed to the preference of non-wearers, suggesting the satisfaction of denture wearers with their current situation. It has been reported that patients who are given dentures sometimes bother to wear them and are usually satised with oral function and appearance (16). On the other hand, dentate individuals tended not to accept an RPDP, which might show prejudice on the

part of those who have never had to wear dentures. Acrylic-resin-based RPDPs, which are covered by the Japanese National Health Insurance, were preferred by participants who placed importance on low treatment cost. In our previous study (15), most dentists selected an implant-supported prosthesis as an optimal treatment in consideration of comfort, function and biological cost. However, these implants were not desired by the elderly, especially among the older group and those with removable dentures. The ndings of this study reconrmed the notion that a patients treatment selection should take into account not only expectations of a successful treatment but also consideration of risk factors and treatment cost. Implants are often not an optimal treatment option in terms of cost-effectiveness and with regard to the risk of side effects. Walton et al. (17) indicated that over a third of mandible edentulous patients did not choose to receive a chargefree treatment for implant-supported overdentures, which suggests expense is not the only impediment to implant treatment. Choices involving surgery may cause anxiety and uncertainty, especially for older people (17). They may be more conservative in their outlook, accept living with physical imperfections and
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SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

have more concerns about their health than younger patients. When patients have a chronic condition, particularly when alternative therapies exist, they want treatment to be cost-effective, rather than just accepting what the therapist deems signicant. Actual costs and insurance availability are key themes to emerge as important factors in the decision-making process. Because nancial resources are limited for most of people, especially in the pensioner, cost-effectiveness must be inuencing the determination of type of dental treatments. It is safe to say that the economic status was associated with higher UV of resin RPDP and lower UV of implant in senior group. Kayser and his colleagues (18) criticized the conventional morphological-oriented approach to the treatment of tooth loss and suggested that such an approach could lead to over-treatment. They therefore proposed the SDA as a treatment option. Treatment with RPDPs is non-invasive to the remaining dentitions structure, but RPDPs can increase the risk of caries, periodontitis and residual ridge reduction, particularly in distal extension areas. In such patients, an SDA approach is a wellprecedented treatment option (10). It was reported that a moderate SDA had little, if any, impact on occlusal stability, tooth loading, temporomandibular disorders, interdental spacing, periodontal disease, patients comfort or masticatory performance (11, 12, 19). Previous surveys of dentists attitudes in several European countries indicated that the SDA concept was accepted by a great majority of dentists but not widely practiced (20). We believe it is similar among Japanese prosthodontists, although we have no evidence. In the Netherlands, qualied members of restorative dentistry were of the view that the SDA concept has a useful place in clinical practice and judged the outcome of SDA management to be generally satisfactory or at least sufcient; however, they applied the SDA concept on a regular or at least occasional basis to <10% of patients in their practices (21). Similarly, in members of the European Prosthodontic Association, 96% of respondents agreed that the SDA concept was acceptable in clinical practice. However, 72% of respondents had treated fewer than 50 patients in this way over the previous 5 years (22). A possible reason for the discrepancies between attitudes of dentists and actual clinical practice is the economic incentive for dentists to treat with prosthodontics options (20). If missing teeth are untreated,
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dentists do not gain economically. The question of the SDA becomes less one of effectiveness of treatment and more one of nances (23). Only one study in the United Kingdom (13) surveyed how patients value the outcomes from different treatments for the SDA. The UVs were the following: cobalt chromium based RPDP: 042; acrylic-resin-based RPDP: 049; implant treatment: 053; resin-bonded cantilevered bridge: 063; conventional cantilevered xed bridge: 064; and no treatment: 028. The researchers concluded that the patients placed a very low value on the outcome from no treatment. They also stated that this nding undermines the view of the WHO and the UK Department of Health, both of which have suggested that 20 standing teeth is an appropriate goal for oral health (13). Participants of this study also placed the lowest value on the SDA without replacement, especially in women and participants who placed an importance on appearance. In contrast, individuals emphasizing low treatment cost tended to accept the SDA. This observation was in line with a previous report in the United Kingdom (13). One possible reason for the lowest value on no replacement is that supraeruption of unopposed posterior teeth, and movement of teeth adjacent to posterior tooth loss have been emphasized in Japanese dental education. In addition to a dentists recommendation, another reason may be that the Japanese National Health Insurance covers RPDPs. Therefore, patients tend to have a sense of their right to have the prostheses. As a result, only a minority of people with loss of teeth remain untreated. Indeed, in our previous survey (not published) of 44 community-dwelling older Japanese with missing bilateral mandibular rst and second molars, 37 patients (84%) were using the RPDPs, although this may be an uncommon phenomenon except for Japan. At any rate, the appropriateness of the SDA as a goal of a prosthetic treatment, even if it is biologically correct, can be questionable from the patients point of view in Japan. Further investigations into the value of the SDA in relation not only to functional but also to psychological effects are needed. The enhancement of the quality of life through a specic prosthetic treatment cannot be assumed to be the same for every patient, even though an improvement has been described for many patients (24). It is important to recognize the limitations of this study. The study population comprised urban Japanese individuals who attended the Senior Citizens College

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courses. Therefore, they might be considered healthier, better educated and more nancially secure than the average older adult in Japan. Most of our subjects had nished high school (89%), and many had at least a college degree (37%). This is a higher educational level than that of the average Japanese in the national survey for the same generation, which reported that 82% had nished high school and 24% had a college degree (25). Only 69% of the subjects reported dissatisfaction with their present nancial status and only 40% of the subjects evaluated their quality of life as poor, suggesting that they might be a more middle-class group than would be found in the general population. Therefore, the study population was comparatively more concerned with oral health and could spend more money for dental treatment than the average person. These situations possibly inuenced the results of this study. Consequently, the results reported here may be specic to this study sample and should be generalized by conrming these associations in other studies of a variety of populations. The most important confounders in prosthetic treatment studies may be the dentist him herself and the applied treatment principle (26). We recognize that our own biases regarding treatment could lead the subjects in a certain direction, although we tried to explain each treatment as fairly as possible with a written description based on a previous study (13). In addition, clinical decisions are inherently associated with considerations of cost-effectiveness when health budgets are limited (6). As stated, the treatment period and estimated expenses were explained to the participants; however, a more detailed description of individualized treatment would be needed in an actual clinical situation. sis, while removable denture wearers prefer a removable denture. At present, the SDA without replacement of missing molars as an oral health goal is questionable from the patients point of view even if it is biologically correct.

Acknowledgments
This research was supported by a Grant-in-Aid for Scientic Research (No. 19390496, principal grant holder: Kazunori Ikebe) from the Japan Society for the Promotion of Science.

References
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Conclusions
Among elderly Japanese people, a cantilever FDP and a metal RPDP were valued the highest, according to individual UV scores, while an SDA was the least valued. The factors inuencing the choices of one treatment option over another varied. The denture wearers rated the value of RPDPs highly, while dentate individuals did not. Implants had a signicantly negative association with individuals wearing dentures and individuals of older age, and an SDA had a signicantly positive association with men and with the self-rated importance of treatment cost. The study suggests that older Japanese adults generally prefer a xed prosthe-

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general dental practitioners. Int J Prosthodont. 2006;19: 171176. Ikebe K, Hazeyama T, Ogawa T, Kagawa R, Matsuda K, Wada M et al. Subjective values of different age groups in Japan regarding treatment for missing molars. Gerodontology. Doi: 10.1111/j.1741-2358.2009.00357. Ikebe K, Nokubi T, Ettinger RL, Namba H, Tanioka N, Iwase K et al. Dental status and satisfaction with oral function in a sample of community-dwelling elderly people in Japan. Spec Care Dentist. 2002;22:3340. Walton JN, MacEntee MI. Choosing or refusing oral implants: a prospective study of edentulous volunteers for a clinical trial. Int J Prosthodont. 2005;18:483488. Kayser AF, Witter DJ, Spanauf AJ. Overtreatment with removable partial dentures in shortened dental arches. Aust Dent J. 1987;32:178182. Torabinejad M, Anderson P, Bader J, Brown LJ, Chen LH, Goodacre CJ et al. Outcomes of root canal treatment and restoration, implant-supported single crowns, xed partial dentures, and extraction without replacement: a systematic review. J Prosthet Dent. 2007;98:285311. Kanno T, Carlsson GE. A review of the shortened dental arch concept focusing on the work by the Kayser Nijmegen group. J Oral Rehabil. 2006;33:850862. Witter DJ, Allen PF, Wilson NH, Kayser AF. Dentists attitudes to the shortened dental arch concept. J Oral Rehabil. 1997;24:143147. Allen PF, Witter DF, Wilson NH, Kayser AF. Shortened dental arch therapy: views of consultants in restorative dentistry in the United Kingdom. J Oral Rehabil. 1996;23: 481485. de Sa e Frias V, Toothaker R, Wright RF. Shortened dental arch: a review of current treatment concepts. Int J Prosthodont. 2004;13:104110. 24. Strassburger C, Kerschbaum T, Heydecke G. Inuence of implant and conventional prostheses on satisfaction and quality of life: a literature review. Part 2: qualitative analysis and evaluation of the studies. Int J Prosthodont. 2006;19:339 348. 25. Ministry of Education, Culture, Sports, Science and Technology. School Education (Summary Tables) Enrollment and Advancement Rate, 1948 to 2005. Available at: http://www. mext.go.jp/english/statist/index01.htm, accessed 3 May 2010. 26. Graham R, Mihaylov S, Jepson N, Allen PF, Bond S. Determining need for a Removable Partial Denture: a qualitative study of factors that inuence dentist provision and patient use. Br Dent J. 2006;200:155158.

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18.

Supporting Information
Additional Supporting Information may be found in the online version of this article: Appendix S1 How you would value the health of your mouth if you had the type of treatment described? Appendix S2 Questionnaire (original in Japanese). Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
Correspondence: Kazunori Ikebe, Department of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka Suita Osaka 565-0871, Japan. E-mail: ikebe@dent.osaka-u.ac.jp

19.

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