Journal of Oral Rehabilitation 1995 22; 397-401

Satisfaction with reduced dentitions in elderly peopleJ . H . M E E U W I S S E N , M . A . J . VAN W A A S , R. M E E U W I S S E N , A . F . K A Y S E R ,M . A . V A N ' T H O F * & W . K A L K Department of Oral Function and Prosthetic Dentistry and * Department of StatisticalConsultation, Faculty of Medical Sciences, Nijmegen, the Netherlands

SUMMARY Natural dentitions of elderly people areoften reduced and the remaining teeth are heavilyrestored. It is unknown whether they are satisfied ordissatisfied with this situation. To get more insightinto this phenomenon 320 dentate non-institution-alized elderly subjects were clinically examined andinterviewed by means of a questionnaire. Analysis ofthe data showed that only 13% of the subjects had atleast a complete dentition from the right first molarto the left first molar; 50% had less than four occlusalunits, 39% of the subjects were wearing a removable

partial denture. Ninety per cent of the subjects wassatisfied with the dental state and nearly all subjectsmentioned they could chew well (97%), despite thefact that 91% of the subjects mentioned they had todeal with one or more dental discomforts. Satisfac-tion decreased significantly when the number of theocclusal units was reduced or a removable partialdenture was present. The conclusion is drawn thatalthough the dentitions of the elderly are often re-duced they are, in general, satisfied with their dentalstate.

Introduction

More often than in the past elderly people retain iheirnatural dentition due to changed patterns of denialawareness and increased lluoride use (Leake, 1988;Hellden, Salonen &Gustalsson, 1989; Palmqvist, Soder-feldl & Arnbjerg, 1991). Since these dentitions oftenhave reduced numbers of teeth, and periodontal tissuesin less than optimal condition, this fact has implicationstor dental treatment. On the one hand, complete re-habilitation ol the dental ardies is otlen impossible orundesirable due to tlie physical and mental condition ofthe subjects or ior financial reasons and, on the otherhand, edentulousness should be avoided. An importantguideline is to maintain an adequate level ol oral func-tion with enough occluding teeth to avoid drastic changesin the mouth (Ettinger, 1987). Kayser (1981) promoteda treatment concept focusing on strategic parts of thedentition in this respect. Witter and co-workers (Witter,Van Eheren and Kayser, 1987, 1988; \N'mcr et al. 1990,1991) reported positive results with this approach in an

adult population. Whether this strategy is also valid inthe elderly is not clear.

To get better insight into this problem, the opinion olelderly subjects regarding their present dental stale isimportant. Several studies have dealt with this subject.Some of them, however, included edentulous subjects(Barenthin, 1977; Berkey, Call & Loupe, 1985), wliileother studies only related satisfaction with the numberof decayed atid missing teeth (Barenthin, 1977; Giddoii,1978; Reisine & Bailit, 1980). The latter fotmd thatsatisfaction decreases with the number of decayed andmissing teeth, but they did not investigate satisfaciioiiin relation to the functional aspects of the remainingdentition.

The purpose of this study was to investigate thesatisfaction wilh reduced dentitions in elderly subjects,especially in relation to the number of occlusal units.

Material and methods

A cross-sectional study was carried out amotig dentate.

397

398 J .H. MEEUWISSEN f/

non-institutionalized elderly subjects between 55 and74 years ol age, living in ZwoUc, a representative city inthe Netherlands (90 000 inhabitants). A name list of3453 subjects was selected by the city registration office.Since age, sex and social economic status (SES) areoften important interfering factors on dental behaviour,two cqual-si/ed age and sex categories were chosen,and subjects iti lour different residential areas includedto obtain a representative sample. All subjects from thename list were personally called alter an introductionletter was sciil to ibcm. Alter cxckiditig 1887 subjectswlio could not be reached (subjects wbo did not have atelephone, whose addresses were incorrect, or wbowere not at home), 1 1 34 subjects who appeared lo havea c()m[)Ictc denture in the tiiaxilla and/or tbe mandible,atui I 12 subjects who rcftiscd to participate, 320 subjectsrcniaiiK'ti wbo had a natutal dctililioti iti both jaws andwatiU'd to partici[)aK'. They were examined near ihcirhotiK' in a dental car. One hutulrcd atid clcvcti of tliemwtTC between 55 and 59 years ol age, 1 30 bctvvcrn 60and 64 and 88 boivveeu 65 and 74. One bundrcd atidthirty-live ol the 329 subjects were male and 194I c male.

Tbe sltidy itivolved a clitiical examitiation and a ques-lioruuiire. The elitiical exatiiitiaiion contaitied itetns coti-ceriiing the [)iesetKe atid quality of the teetli, ibe tumi-ber ol oeelusal titiiis, atui the ptesence and desigti of aretriovable partial denliire (RFD). An occkisal Litiii is, inthis eonlexi, tielined as a pair oi oceltiditig teeih iti tbe(losu'rior tegioiT. In ease both oeeluding leetb weretiaun\il leelh, the tiiiit was scored as a naliiral oeelusalLttiil'; iti ease one loolh was arlilieial or bolli teeth wereartilicial, ilie oetlusal tiiiii was seored as artifieiaT. Foratialyses a loial seore lor llie {letiiiiioti vvas tnade. 'No

units' was seoted wben, al both [loslerior sites, tio oeelttsalunits existed. 'Few unils' was seored vvbeti, al otie sile,no units existed and al ibe otber one lo lour, or when,at both sites, no more than iwo utiits existed. 'Moderate

units' was seoted when, at one sile, at leasi one occlusaltitiit existed atid. al the other, al least ihree nnils. A'ioiitptctcilcritition' was seored wlieti there was a cotiipleledetuitioti Ifotn the right litsi molar to llie lett first tnolarin ihe maxilla atui mandible.

The qttesliotmaire eotitaitied quesiiotis with precededanswers with respeei lo subjecis' opitiioti abotti thelunelion ol the dentiiioti and of the RPD. Besides qttes-ticHis on genetal satisfaeiion with the detital slate specificquestions were asked concerning conifori, chewing,aestheiies, speech, dental experiences in the past anddental attitude.

For analysis of the relationship of satisfaction with

other variables a 'general satisfactioti' scale was con-

structed by factor analysis using 11 questions out of the

questionnaire. The scale was a sum score of questions

regarding problems and complaints with the dental

state and questions regarding chewing, appearance,

speech and perception oi oral health. Tbe reliability

analysis showed a Cronbach's alpha ol 0-75 lor the

scale. Statistical analyses were performed using a /-lest

and variance analysis.

Results

Clinical slate of the dentition

Figures 1 and 2 show the distribution of tbe present

leeth and leeih replaced by an RPD or bridge dummies.

Natural teeth appeared lo be most often present in the

Percentages

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Tooth number

Fig. 1. A griiphit presentation ol ihc presence of teeth, the teeth

rejiLiccd by tin Rl'I), and the presence of a fixed bridi^e dummy for

llie maxilLi (F.O.I, notation), s . present teeth; 53, replaced by

dummy;" ' , replaced hy RPI).

Percentages

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Tooth number

Fig. 2. A graphic presentation of the presence of teeth, the teethreplaced by an RPD, and the presence of a fixed bridge dummy forthe mandible (F.D.I, notation), s . present teeth; 23, replaced bydutiitiiy;G, leplaced by RPD.

Journal of Oral Rchabililalion 22;

REDUCED DENTITIONS IN ELDERLY PEOPLE 399

frontal region. RPDs replaced teeth most often in theposterior regions: in 20% of the subjects in the maxillaand 15% in the mandible. Molars were not replaced in20% of the subjects in the maxilla and in almost 40% inthe mandible. The anterior teeth and the first premolarswere almost always replaced if not present.

The average number of the occlusal units per subjectwas 4-1. Table 1 shows that 13% of the subjects had acomplete dentition and 50% of the subjects had no orfew units (less than four). When natural and artificialteeth are taken together, this resulted in more occludingunits: the highest percentage contained the categorywith four to seven occlusal units (moderate units).

Thirty-nine per cent of the subjects were wearing anRPD, of which 61%. were acrylic dentures and 64% offree-end design. Anterior replacements were present in39%. The degree of dental care was high (52% of theteeth were restored), but the need for restoration waslow (76% did not need any restoration in the coronalp- of the tooth and 88% not in the root part). Eight

. -cnt of the subjects had more than one tooth witha pocket e' )ve 5 mm. Attrition and abrasion werecommon features, and extreme wear seldom occurred(5%).

Opinion about the dental state

The answers to the questions with respect to generalsatisfaction with the dentition and functioning of thedentition are shown in Table 2. Ninety per cent of thesubjects gave a positive answer on the question if theywere satisfied with their dental state, 15% mentionedthey could not bite hard foods and 29% was not satisfiedwith their dental appearance. Problems with speechseldom occurred.

Regarding the question 'Have you had any complaintsin the last year caused by toothache, broken fillings orsomething else?', 53%) answered negatively and 47%jpositively. Dental discomforts — referring to some incon-

Table 1. Distribution ol the subjects according to the number ol

natural and artificial occlusal units

Natural units Natural and artificial units

Table 2. Answers to questions regarding the subjects' opinionabout the functioning of ihe dentition

Are you satisfied with your dentaf state.'very satisfied 307o, satisfied 60%, nol satisfied fO"/,,

Can you chew all your foods well?yes 97%. no 3%

Can you bite bard food such as apples?yes 85%. no f 5%

Are you satisfied with your dental appearance?very satisfied f4"/(>, satisfied 57%, not satisfied 29%

Do you have problems witb speech?no 88%, sometimes 10%, irec)uently 2%

veniences like food packing, tooth mobility, painfulteeth when eating hot or cold food — were frequentlymentioned: 16%) of the subjects reported several dis-comforts and 9% of subjects did not have any discomfortexperiences. This means that 91% reported at least onediscomfort.

Eighty-five per cent of the subjects assessed their oralhealth as 'good' or 'fair'. Compared to other people,86%) thought they were in a better dental state. Fifty-nine per cent of the subjects mentioned that they hadnever had any problems with their dentition in the pastand for 65%) of the subjects the last tooth extraction wasmore than 3 years ago. Most subjects visited their dentistat least once a year (86%).

Relationship between satisfaction and the dental state

Table 3 shows the relationship between the scores onthe 'general satisfaction' scale and the number of oc-clusal units for natural dentitions and the presence of apartial denture. It appears that general satisfaction rosesignificantly with the increasing number of occlusalunits both for subjects with a natural dentition and forsubjects with a partial denture. Both variables had asignificant effect on general satisfaction (ANOVA, F —

Table 3. The average generaf satisfaction scores according to thenumber of the occhisal natural units in the dentition and tbepresence of an Rf̂ f)

Natural denlitionN = 193

RPf) wearerN = 127

TotalN = 320

No units

Few units

Moderate units

Complete denti t ion

Total

28

132

f20

40

320

9 %

4 f "/<,

3 8 %

f 3 %

f 0 0 %

f2

9 3

f75

40

320

4"/o

2 9 %

5 5 %

f 3 %

fOO%

No units

Few unils

Moderate units

Complete denti t ion

Total

7-7

f f I

12 f

f4 0

f2 1

4 8

9 6

10 4

—

9 8

6 310 3

f f 414 0

f f 2

Journal of Oral Rehabilitation 1995 22; 397-401

400 J .H. MEEUWISSEN et al

0-001 and P= 0-01). No interaction between these vari-ables was present, which means that type and design ofthe RPD and the number of occlusal units did notincrease or decrease each other's effects. A significantdifference also existed between the general satisfactionscores of the subjects with and without an RPD (/-test,P<0-05).

Discussion

In studies of the dental state and satisfaction in efderlypeople edentulous people are usually included. Thecomparison with studies is therefore difficuft. Apartfrom tliis, most studies differ due to variations in selec-tion and stratification of subjects and demographic pat-terns. The selective character of this sample could alsoplay a role in explaining differences between the resultsof this study and data from the literature. No comparisonwith data in the literature, therefore, is made.

Only 137<) of the subjects had a complete dentitionfrom the right first molar to the left first molar. Thedentition of 39% of the subjects was in such a conditionthat an RPf) was applied. Many reduced dentitions werepresent, fn spite of tliis, 90y(, of the subjects weresatisfied with tficir dental state and 97% could chewwell.

Although many subjects were satisfied, half of themmentioned having some complaints last year and 91%of the suhjc'cis reported \o one or more discomforts. Theexplanation for this phenomenon could be that elderlypeople do not directly relate being satisfied to existingdental complaints: the attitude of cfdcrly sufijccts towardsoral hcvilth might ratlicr be a reflection of tfieir generalacceptance of decreasing health (f<iyal<, 1981). Anotherreason migfit be the influence of good general health. Astudy by Tornstam (f 975) showed that the presence of aserious disease is one of the most important determi-nants for perceived subjective health. A high percentageof subjects in this study considered themselves in goodgeneral health (Mccuvvisscn, 1992); this suggests a highlevel of psychological well-being and may be an expla-nation of the high general satisfaction scores.

Most subjects had a positive attitude towards theirdental state and had hardly any problems in the past:they had their dentition regularly checked by a dentist.This suggests that the dental situation already existedfor a longer period and could be considered stable. Thiscannot he proven, however, since this was a cross-sectional study.

Several studies (Helkimo, Carlsson & Helkimo, 1978;Chauncey et al, f 981) found that the objective chewingperformance decreases with the number oi teeth andage. Elderly people need more chewing strokes beforethe swallowing threshold is reached and the particle sizeis bigger when swallowing (Agerberg & Carlsson, 1981;Gunne, 1985; Idowu, Graser & Handelman, 1986). Forthese reasons one would expect a lower percentageof subjects in this study who are satisfied with theirchewing ability, but this was not found. This finding canbe explained by the phenomenon often found in theliterature that patients' opinions regarding their chewingfunction does not agree with the results of objectivetests (Agerberg & Carlsson, 1981; Wayler & Chauncey,1983; Slagter et al. 1992).

Subjects with few natural occlusal units or with anRPD had lower scores on the general satisfaction' scale.The satisfaction scores between subjects with few andmoderate occlusal units, however, hardly differed. Asignificant change appears when no units are present.This agrees with the results of Witter el al (1990).

Sufijects with an RPD were less satisfied than subjectswith a natural dentition. The findings confirm the resultsof other studies: partial dentures often give problems,especially dentures with free-end saddles (Chandler &Brudvik, 1984; Waison ct al, 1986) or acrylic dentures(Watson et al, 1986). Both types are often present inthis sample. Reduced dentitions without replacement ofthe missing teeth by an RPD, however, only give prob-lems when the number of occlusal units is too small(Witter ^/^/., f987, 1988, 1990, 199f).

Conclusions

In this study amongst elderly people most subjects weresatisfied with the present dental state, although manydetuitions were reduced. They juciged the chewing func-tion and speech as good. Discomforts, however, wereoften mentioned.

Most of the subjects had a positive attitude towardstheir dental state: they were regular dental visitors andhad hardly any problems in the past.

Subjects with few natural occlusal units, or with anRPD, were less satisfied with their detital state.

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Correspondence: Dr M.A.J. van Waas, Department of Oral Function

and Proslht'tic Dentistry, Faculty of Medical Sciences, PO Box

6300 HB Nijmogfn, the Netherlands.

Journal of Oral Rehabilitation 1995 22: 397-401