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Abstract
Background: Although the use of removable dentures can improve oral function and esthetics for elderly people,
compared to those who do not wear removable dentures, those wearing removable dentures could have worse
oral health related-quality of life (OHRQoL). Additional information is required to assess which factors related to
denture wearing influence the OHRQoL of elderly individuals. The purpose of this study is to evaluate the
association between denture wearing and OHRQoL in a sample of elderly individuals in Taiwan.
Methods: The study population included 277 elderly people wearing removable dentures (mean age = 76.0 years).
Using face-to-face interviews, we collected data on the participants’ socio-demographic characteristics, dental care
service usage (regular dental checkups, treatment during toothache, dental visits in the last year), and factors
related to denture wearing (perceived oral pain, perceived loose denture, perceived oral ulcer, perceived halitosis,
perceived dry mouth, and perceived total denture satisfaction scores). OHRQoL was measured using the Taiwanese
version of the Geriatric Oral Health Assessment Index (GOHAI-T). The location and number of remaining natural
teeth and the type of denture were also recorded. Hierarchical multiple regression analysis was performed using
GOHAI-T scores as the dependent variable.
Results: All the predictors together accounted for 50% of the variance in GOHAI-T scores. Further, education
level, number of natural teeth, denture status, perceived loose denture, perceived oral ulcer, and perceived
total denture satisfaction scores had statistically significant influences on OHRQoL. When compared with other
variables, factors related to denture wearing, especially perceived total denture satisfaction scores, had the
greatest impact on GOHAI-T scores.
Conclusions: Of the factors analyzed in this study, denture satisfaction was the strongest predictor of OHRQoL. This
suggests that denture satisfaction is useful for assessing the effect of denture treatment on the OHRQoL of elderly
individuals wearing removable dentures.
Keywords: Elderly, Removable dental prostheses, Oral health-related quality of life, Geriatric oral health assessment
index, Denture satisfaction, Dental care service
* Correspondence: taihen.n4545@msa.hinet.net
9
Division of Family Dentistry, Department of Dentistry, Kaohsiung Medical University
Hospital, Kaohsiung, Taiwan
10
Department of Dentistry, Kaohsiung Municipal Ci-Jin Hospital, Kaohsiung,
Taiwan
Full list of author information is available at the end of the article
© 2015 Yen et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
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The answers of questions were scored by 5=always(總是), 4=usually(經常), 3=occasionally(偶爾), 2=seldom(很少), and 1=never(從不). The scores were reversed
in the 3rd, 7th and 12th questions.
The internal consistency of the DSA (Cronbach’s alpha) total denture satisfaction score was significantly associ-
was assessed in the presence and absence of each item for ated with good general denture satisfaction.
the subjects. Cronbach’s alpha was 0.887for the total scale Our data indicated that the skewness and kurtosis of
and ranged between 0.857–0.881 for each item, indicating GOHAI-T distribution were −0.77 and 3.25, respectively,
that the DSA had highly acceptable reliability. The conver- and that these values were more normalized than the
gent validity of the DSA was assessed using Spearman’s square-root-transformed GOHAI-T distribution (skewness =
rank correlation coefficient by examining the correlation −1.02 and kurtosis = 3.89) or log-transformed GOHAI-T dis-
between total denture satisfaction scores and the general tribution (skewness = −1.07 and kurtosis = 4.81). Hence, the
satisfaction of the sample subjects. The Spearman’s rank raw GOHAI-T scores were chosen for multiple linear regres-
relation coefficient was 0.7583 (p < 0.001), which sup- sion analysis. Moreover, we conducted a robust linear regres-
ported the convergent validity and showed that a high sion to confirm the analysis results and found that all the
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statistically significant variables in the results of the robust re- Table 2 Participants’ characteristics (N = 277)
gression were the same as those obtained using general mul- Variables n %
tiple linear regression. Robust regression methods are Socio-demographic characteristics
designed such that they are not overly affected by violations Gender
of assumptions by the underlying data-generating process
Male 131 47.3
[33].
To assess the impacts of different blocks of predictors on Female 146 52.7
OHRQoL, we conducted hierarchical multiple regression Age (years)
analysis using all independent predictors, with variance infla- 65–69 79 28.5
tion factors under 5 to avoid multicollinearity in the whole 70–79 106 38.3
model. The analysis was performed to determine the most ≥80 92 33.2
predictive block of variables based on the GOHAI-T scores.
Mean ± SE (range) 76.8 ± 0.4 (65–90)
The GOHAI-T score was used as a dependent variable and
the blocks of independent variables were entered in the fol- Education level
lowing steps: Step 1: socio-demographic characteristics, Step Less than high school 89 32.1
2: dentition and denture status, Step 3: dental care service High school or above 188 67.9
usage, Step 4: factors related to denture wearing. R2 shows Living status
the percentage of variability in the dependent variable that Alone 52 18.8
can be accounted for by all predictors. The change in R2 can
With others 225 81.2
be used to measure the amount of predictive power added
to the model by the addition of another block of variables in Able to afford living expenses
the next step. We compared the standardized regression co- Yes 218 78.7
efficients of independent variables to determine their impact No 59 21.3
on the GOHAI-T scores. Dentition and denture status
Remaining natural teeth
Results
Mean ± SE (range) 7.78 ± 0.4 (0–26)
The basic characteristics of the study population are pre-
sented in Table 2. Data were collected from 277 subjects Denture status
who wore removable dentures. More than half of them Full-mouth complete denture 69 24.9
were women (52.7%), the mean age (± standard error) Single complete denture 69 24.9
was 76.8 (±0.4) years, two-thirds had a level of education Single partial denture 68 24.6
of high school or above (67.9%), the majority were living Full-mouth partial denture 71 25.6
with others (81.2%), and more than three-fourths were
Dental care service usage
able to afford their living expenses (78.7%). Further, the
mean number of natural teeth was 7.8 ± 0.4. The distri- Regular dental checkups 62 22.4
bution of the denture status was as follows: full-mouth Treatment during toothache 30 10.8
complete denture, 24.9%; single complete denture, 24.9%; Dental visits in the last year 109 39.4
single partial denture, 24.6%; and full-mouth partial den- Factors related to denture wearing
ture, 25.6%. Those who had regular dental checkups, Presence of oral pain 24 8.7
treatment during toothache, and dental visits in the last
Perceived loose denture 51 18.4
year accounted for 22.4%, 10.8%, and 39.4% of the popula-
tion, respectively. Regarding factors related to denture Presence of oral ulcer 28 10.1
wearing, 24 (8.7%) subjects always/often presented with Perceived halitosis 21 7.6
oral pain, 51 (18.4%) perceived that they had a loose den- Perceived dry mouth 31 11.2
ture, 28 (10.1%) had an oral ulcer, 21 (7.6%) had perceived Total denture satisfaction scores
halitosis, 31 (11.2%) had perceived dry mouth, and the Mean ± SE (range) 19.0 ± 0.3 (6–30)
total denture satisfaction score was 19.0 ± 0.3. In terms of
Oral health related quality of life Mean ± SE (range)
the OHRQoL, the mean (± standard error) scores of the
GOHAI-T subscales of PF, PSF, and PD were 47.8 ± 0.5, GOHAI-T scores 47.8 ± 0.5 (22–60)
14.3 ± 0.2, 20.8 ± 0.3, and 12.7 ± 0.1, respectively. Physical function 14.3 ± 0.2 (4–20)
Gender, education level, living status, ability to afford Psychosocial function 20.8 ± 0.3 (5–25)
living expenses, denture status, regular dental checkups, Pain and discomfort 12.7 ± 0.1 (3–15)
treatment during toothache, and dental visits in the last
year were not significantly associated with PF, PSF, PD,
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and total GOHAI-T scores. However, subjects who had was translated by the researchers and was examined among
oral pain, perceived that they had a loose denture, had an a convenience sample of elderly subjects in Kaohsiung City
oral ulcer, and perceived that they had halitosis had lower for its construct validity and internal reliability. Therefore,
PF and total GOHAI-T scores. Further, those who had per- further studies may be required to determine whether this
ceived dry mouth had lower GOHAI-T scores (Table 3). version can be applied to the elderly Taiwanese population.
Denture satisfaction scores were positively associated To enable the development of patient-oriented ap-
with PF, PSF, PD, and GOHAI-T scores. We also found proaches in public health care and provide appropriate
that the PF and PSF scores were significantly lower for oral health care to elderly people wearing removable
subjects with a lower number of natural teeth. However, dentures, it is important to know which predictors actu-
age was not significantly correlated with PF, PSF, PD, ally affect the OHRQoL of elderly people. Therefore, the
and total GOHAI-T scores (Table 4). present study aimed to assess the factors of OHRQoL
Hierarchical multiple regression was performed to investi- among elderly people wearing removable denture. Re-
gate the ability of factors related to denture wearing to pre- sults of the hierarchical multiple regression showed that
dict GOHAI-T scores, after controlling for socio- factors related to denture wearing were most strongly
demographic variables, dentition and denture status, and associated with OHRQoL, with denture satisfaction be-
dental care service usage. Socio-demographic characteristics ing the strongest predictor of OHRQoL, and the num-
were entered in Model I and this model was not statistically ber of remaining natural teeth was the second highest
significant, F (5, 271) = 1.99, p > 0.05. We added dentition predictor. In addition, the OHRQoL of elderly people
and denture status to the socio-demographic characteris- wearing removable dentures could also be predicted by
tics in Model II, and the model as a whole explained a total education level, denture status, perceived loose denture,
of 12.4% of the variance, F (9, 267) = 4.20, p < .001. The and presence of oral ulcer. Thus, among the predictors an-
education level, number of natural teeth, and denture sta- alyzed in this study, denture satisfaction was the best pre-
tus were predictors of GOHAI-T scores. In Model III, fac- dictor of OHRQoL of elderly people wearing removable
tors related to denture wearing were added, and the total dentures.
variance explained by the model as a whole increased to The findings of this study suggested that high satisfac-
52.4%, F (15, 261) =19.13, p < 0.001. The introduction of fac- tion with removable dentures was significantly related to
tors related to denture wearing explained an additional 40.0% a high GOHAI-T score, indicating a low level of impair-
of the variance in GOHAI-T scores, ΔR2 = 0.40, F (6, 261) = ment of OHRQoL. This is in line with the findings of
36.50, p < 0.001. Dental care service usage was added in previous studies that showed a positive correlation be-
Model IV, and the total variance explained by the model was tween self-reported denture satisfaction and OHRQoL in
53.3%, F (18, 258) = 16.3, p < 0.001. The introduction of dental the elderly [23]. In their 2-year longitudinal analysis,
care service usage explained an additional 0.9% of the vari- Stober et al. [19] showed that elderly patients’ satisfaction
ance in GOHAI-T scores, ΔR2 = 0.009, F (3, 258) = 1.68, p > with complete dentures was associated with OHRQoL,
0.05. In the final model, 6 of 18 predictor variables were sta- based on scores on the shortened version of the OHIP.
tistically significant, with denture satisfaction having a higher Recently, Kuo et al. [7] reported that patients’ satisfaction
beta value (β = 0.45, p < .001) than the remaining natural teeth with complete dentures was significantly related to an
(β = 0.26, p < .001), denture status, perceived loose denture, improvement in their OHRQoL, as measured using the
presence of oral ulcer, and educational level (Table 5). OHIP-14. In their cross-sectional analysis, Lee et al.
[10] showed that if the elderly are satisfied with their
Discussion dentures, OHRQoL, assessed using the OHIP, may be
Despite the important findings, our study had several limita- unaffected by oral health problems.
tions that should be considered with some caution when A recent study described a positive correlation be-
interpreting the results. First, we did not use a population- tween professional ratings of removable denture quality
based sample, but a convenience sample from the Senior and a low OHIP score, indicating a low level of impair-
Citizens’ College of Kaohsiung City, and thus, our study rep- ment of OHRQoL [29]. However, a poorly fitting den-
resents only a subgroup of the public. Future research ture may be well tolerated in one person, while a well
should focus on generalizing the findings to the elderly Tai- fitting denture may create problems for another [30].
wanese people wearing removable dentures. Second, the Garrett et al. [34] reported that 55% of 21 patients with
present study is characterized by a cross-sectional design, poorly fitting denture [31] had moderate-to-complete
and therefore, we cannot make inferences with respect to denture satisfaction, which was found by the examining
the direction of the observed associations. The third limita- dentists assessing need for denture replacement. Närhi
tion was related to the study instrument. Because no a Chin- et al. [35] found a weak or statistically nonsignificant
ese version of the GOHAI for Taiwanese had been validated correlation between patients’ denture satisfaction and
when the study was performed, the original English version clinical measurements such as anatomic conditions, as
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Table 4 Correlations among oral health-related quality of life, age, and denture-related factors (N = 277)
Variables Physical function Psychosocial function Pain and discomfort GOHAI-T score
(Maximum score = 20) (Maximum score = 25 ) (Maximum score = 15) (Maximum score = 60)
Coefficients Coefficients Coefficients Coefficients
Age (years) 0.01 −0.05 0.09 0.01
Remaining natural teeth 0.17* 0.25* 0.06 0.03
Total denture satisfaction scores 0.65* 0.55* 0.56* 0.45*
Satisfaction with chewing ability 0.54* 0.49* 0.43* 0.35*
Satisfaction with ability to speak clearly 0.56* 0.47* 0.49* 0.38*
Satisfaction with appearance 0.43* 0.31* 0.43* 0.29*
Satisfaction with tasting ability 0.49* 0.44* 0.40* 0.31*
Satisfaction with retention of 0.50* 0.43* 0.40* 0.35*
dentures (total,estimate)
Satisfaction with comfort (total, estimate) 0.52* 0.40* 0.47* 0.40 *
*p < 0.05.
well as denture quality. Thus, denture satisfaction is not OHRQoL than their counterparts without oral ulcer
based on the technical quality of the dentures alone. experiences. This finding is consistent with the results
Moreover, Turker et al. [30] suggested that although pa- of many previous studies showing that oral ulcers were
tients seek technical advice, psychological and emotional associated with a poor OHRQoL [37]. In a study evalu-
factors play an important role in their poor adaptation ating the sensitivity of patient-centered outcome mea-
to the denture. Another study showed that the dentist– sures to treatment, McGrath et al. [34] suggested that
patient relationship and psychological factors had a great patients with ulcers and symptomatic oral mucosal lesions
impact on patients’ acceptance of and adaptation to re- had poorer OHRQoL (measured using the OHIP-14) than
movable dentures [33]. Therefore, in addition to clinical their counterparts with non-symptomatic lesions. Re-
and technical skills, gaining a better understanding of cently, Suliman et al. [13] showed that oral ulcerative
patient behavior and psychology, and improving com- lesions were significantly associated with oral impacts
munication are crucial to improving patients’ denture on daily performance, indicating poor quality of life.
satisfaction [30,33]. Moreover, Mandali et al. [38] suggested that recall
In the present study, subjects with a perceived loose visits and shortened denture usage are essential for
denture gained significantly lower mean GOHAI-T scores, prevention of oral mucosal lesions. Therefore, to im-
indicating a worse OHRQoL than those without a per- prove OHRQoL of elderly population, it is important
ceived loose denture. This result is in accordance with to educate and regularly review patients who wear den-
those of previous studies [23] showing that denture loos- tures with regard to oral tissue injuries.
ening was a significant contributing factor to low OHR- Our results demonstrated that the number of remaining
QoL. Moreover, Hassel et al. [11] showed that improving natural teeth was positively associated with OHRQoL;
retention of previously insufficiently retained dentures thus, the larger the number of remaining natural teeth,
was positively associated with OHRQoL, as measured the lower the impact on the OHRQoL. This result was in
using the OHIP-49 (German version), among removable accordance with those of many previous studies [12,16].
denture wearers. Hassel et al. further indicated that den- Zaitsu et al. [17] suggested that the number of missing
ture loosening affects many aspects of quality of life, both teeth was significantly associated with low GOHAI
psychological and social. Komagamine et al. [22] also re- scores, indicating a poor OHRQoL. In their meta-
ported that sufficient retention of lower dentures is im- analysis, Gerritsen et al. [18] showed that tooth loss is
portant to improving OHRQoL in edentulous patients. associated with impairment of OHRQoL, and this as-
Hence, it is necessary to identify and improving retention sociation seems to be independent of the OHRQoL as-
of previously insufficiently retained dentures in order to sessment instrument used and the context of the included
improve the OHRQoL of elderly persons wearing remov- samples. Moreover, Jain et al. [12] indicated that a de-
able dentures. crease in the number of remaining natural teeth was
Removable dentures can injure oral tissues, and their correlated with poor OHRQoL, independent of the ef-
use is associated with a high frequency of oral mucosal fect of age and gender. Therefore, they concluded that
lesions [36]. In the present study, subjects who had all populations with complete natural dentition show a
had an oral ulcer were more likely to report a poorer good OHRQoL.
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Our study also showed that denture status was a pre- to people with natural teeth, those who wear removable
dictor of OHRQoL, as measured by the GOHAI-T, and dentures experience more significant negative impacts on
that removable partial denture (RPD) wearers experi- social and emotional aspects of life. Another possible
enced a more adverse impact of the dentures on their reason may be that the subjects in this study were
OHRQoL than did complete denture wearers. Another sourced from the Government Senior Citizens’ Service
study found that RPD users experienced impaired OHR- Center in Taiwan. Elderly people attending this center
QoL more often than did CD users, based on responses tend to have a higher education level and better socio-
to the OHIP [39]. In addition, Wong et al. [21] reported economic status. Subjects with a higher level of educa-
that in a sample of community-dwelling elderly Chinese tion may have higher expectations relating to their oral
people, those who wore RPD experienced a greater OHR- health satisfaction and, accordingly, be more likely to
QoL impairment (measured by the GOHAI) than did CD have lower GOHAI-T values [15].
wearers. These findings probably result from the un- The present study was performed in 2009, at which
realistic expectations of the wearers from their den- time the GOHAI had not yet been translated for use in
tures, i.e., RPD wearers tend to compare their dentures Taiwan. A Chinese version of the GOHAI for older
with natural teeth. In contrast, researchers have shown people living in Hong Kong and southern China was de-
that CD wearers have usually previously used RPD and veloped in 2002 [41]. Though the Taiwanese language is
might accept the lack of teeth and oral discomfort as a influenced by Chinese culture, there are a number of dif-
part of the aging process. Thus, CD wearers might be ferences between the spoken and written Chinese of
more accepting of the limitations of denture functions Hong Kong and that of Taiwan, so, the wording of the
than RPD wearers are [22,39]. questions in the Chinese version of the GOHAI could
In our study, educational level had a significant influ- confuse elderly Taiwanese individuals. Therefore, in the
ence on GOHAI-T scores. Subjects with a higher educa- current study, we did not use the Chinese version of the
tion level were more likely to have poorer OHRQoL, GOHAI for assessing OHRQoL measures. Instead, a
indicating more perceived dental problems in this group Chinese version of the GOHAI for use with Taiwanese
than in those with an education level lower than high people specifically (GOHAI-T) was developed.
school. A possible explanation for this trend may be re- A strength of the current study was that we simultan-
lated to a person’s expectations. Subjects with a lower eously controlled both for factors related to denture
level of education may have lower standards or expecta- wearing and for relevant influencing factors mentioned
tions in their evaluation of health satisfaction or life sat- in previous similar studies. In the final model, the overall
isfaction and, accordingly, be more likely to be satisfied explanatory power was 0.533. The present findings con-
than those who are more highly educated [40]. Another firmed that factors related to denture wearing were most
possible reason is that subjects with a higher education strongly associated with OHRQoL, with denture satisfac-
level may be more concerned about problems with oral tion being the strongest predictor. Therefore, in clinical
health and esthetics than those with a lower education praxis, denture satisfaction is a useful tool to evaluate
level are, as this may be less accepted in the social circles the effect of denture treatment on OHRQoL. However, a
of those who are more highly education. Therefore, weakness of the study was that the nature of the causality
those with a lower education level and lower expecta- in which denture satisfaction is used to predict OHRQoL
tions may report higher GOHAI-T scores, indicating a was still unclear due to the cross-sectional design. There-
better OHRQoL. fore, OHRQoL could not be measured by the total den-
Compared to other international literature dealing with ture satisfaction score instead of the GOHAI-T score.
OHRQoL in the elderly, we found lower GOHAI-T values
in this study. One possible reason for this is that the sub- Conclusions
jects in this study were elderly individuals wearing remov- In conclusion, of the factors analyzed in this study, those
able dentures. Hogenius et al. [8] showed that compared related to denture wearing were most strongly associated
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Author details 18. Gerritsen AE, Allen PF, Witter DJ, Bronkhorst EM, Creugers NHJ. Tooth loss
1
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Medical University, Kaohsiung, Taiwan. 2School of Dentistry, College of Health Qual Life Outcomes. 2010;8:126–36.
Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. 3Division 19. Stober T, Danner D, Lehmann F, Séché A-C, Rammelsberg P, Hassel AJ.
of Prosthodontics, Department of Dentistry, Kaohsiung Medical University Association between patient satisfaction with complete dentures and
Hospital, Kaohsiung, Taiwan. 4Division of Periodontics, Department of oral health-related quality of life: two-year longitudinal assessment.
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5
Department of Healthcare Administration, College of Health Science, Asia 20. John MT, Koepsell TD, Hujoel P, Miglioretti DL, LeResche L, Micheelis W.
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Department of Dentistry, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, 21. Wong MC, McMillan AS. Tooth loss, denture wearing and oral health-related
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10
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doi:10.1186/1472-6831-15-1
Cite this article as: Yen et al.: Impact of removable dentures on oral
health-related quality of life among elderly adults in Taiwan. BMC Oral
Health 2015 15:1.