Patient well-being is always the goal of rehabilitation of edentulism; however, evaluations of treatment success often overlook the patient's subjective feelings about comfort, function, speech, social image, social inhibitions, psychological discomfort, and/or disabilities. The purpose of this study was to assess these patient responses using an oral health questionnaire. To assess such feelings, a self-administered 20-question multiple-choice patient-reported Edentulous Patient Impact Questionnaire was developed, based upon the previously validated Oral Health Impact Profile patient-assessment tool. Responses were solicited from randomly selected patients treated with an implant-supported, fixed, immediately loaded full arch prosthesis. The questionnaires were completed by 250 patients. Of the respondents, 95% described themselves as being either extremely satisfied (74%) or satisfied (21%) with their new teeth, and 98% said they would definitely recommend similar treatment (88%) or consider recommending it (10%) to a friend or colleague. Based upon an oral health impact survey completed by 250 patients treated with full-arch implant-supported, immediately loaded fixed dental prostheses, it appears that patient satisfaction is high and that treated patients would generally be willing to recommend this treatment to others.

Introduction

The original Branemark protocol for successful implant osseointegration required a healing period of 3–6 months during which the implants were submerged to protect them from premature loading.1,2  As implant dentistry advanced, the 2-stage approach was modified into a 1-stage process. In this procedure, transmucosal components are immediately connected to the implant, and an immediate prosthetic loading protocol may be applied without compromising osseointegration, provided that primary stability of the implant can be maintained when controlled occlusal loads have been established.35  In other instances, the 3- to 6-month healing phase is adhered to, and in cases where grafting procedures are necessary, the healing time also may increase.

The observation was made that the primary reason for an undisturbed healing period was to avoid implant micromotion. Once this realization became evident, techniques developed for the immediate splinting of implants in an effort to provide cross-arch stability and thereby reduce motion. Hence, the immediate use of provisional restorations was initiated.6  Since then, excellent success rates for immediately loaded, fixed prosthetic reconstructions and long-term follow-up results have been widely reported.712 

With varied approaches to implant treatment and increasing patient participation in healthcare decision-making, the ability to quantify well-defined treatment outcomes, including patient satisfaction and posttherapeutic oral-related quality of life, has become increasingly important. Assessment of treatment outcomes using surveys designed to elicit subjective responses from patients appears to be an appropriate method of evaluation. Approaches to doing so include the Geriatric Oral Health Assessment Index,13  the Oral Health Impact Profiles (OHIP-49,14  OHIP-14,15  and OHIP-EDENT16 ), and the Dental Impact Profile.17 

For the most part, however, such measures have been cumbersome to administer, and their use has been confined to academic settings. Moreover, previous studies have not focused on exploring the impact of dental implants on daily living.

The purpose of this study was to develop an easily administered patient-outcome survey to assess comprehensively patient experiences with a novel approach to full-arch implant rehabilitation.

Materials and Methods

A self-administered 20-question multiple-choice survey, the Edentulous Patient Impact Questionnaire (EPIQ), was designed, based upon the previously validated OHIP-14 patient-assessment tool. The new survey was specifically intended to assess how edentulous patients receiving full-arch immediately loaded implant restorations (in one arch or both) rated factors in the domains of function, comfort, esthetics, and perceived value.

The questionnaire was submitted to the Independent Review Consulting, Inc, California, and received an exemption EXE10.007.01. The questionnaire is reproduced in Figure 1.

Figure 1.

Edentulous Patient Impact Questionnaire.

Figure 1.

Edentulous Patient Impact Questionnaire.

Between February 17 and October 27, 2010, the survey was randomly presented to patients who had received All-on-Four treatment for one or both jaws using tapered NobelActive implants (Nobel Biocare AB, Goteborg, Sweden) at the ClearChoice Dental Implant Center, Cleveland, Ohio. The All-on-Four treatment concept enables delivery of a fixed provisional prosthesis on the same day that 4 implants are placed into the edentulous arch (mandibular or maxillary, healed or immediately after tooth extraction). Two anterior implants are positioned vertically, while 2 more posterior implants are tilted distally. Cumulative survival rates ranging between 92.2% and 100% have been reported for implants placed using the All-on-Four concept.1822 

Figures 2 through 4 illustrate before and after results for 3 patients treated with the All-on-Four concept.

Figure 2.

(a) Preoperative panoramic view of cone-beam computed tomography scan of the edentulous maxilla and mandible. (b) Preoperative clinical view of the maxilla. (c) Preoperative clinical view of the mandible. (d) Immediate postoperative panoramic radiograph demonstrating the maxillary and mandibular All-on-Four implants in position. (e) Postoperative follow-up clinical photograph of the fixed implant bridge from a frontal view in both the maxilla and mandible. (f) The 34-month postoperative periapical follow-up radiographs of both the maxillary and mandibular All-on-Four implants.

Figure 2.

(a) Preoperative panoramic view of cone-beam computed tomography scan of the edentulous maxilla and mandible. (b) Preoperative clinical view of the maxilla. (c) Preoperative clinical view of the mandible. (d) Immediate postoperative panoramic radiograph demonstrating the maxillary and mandibular All-on-Four implants in position. (e) Postoperative follow-up clinical photograph of the fixed implant bridge from a frontal view in both the maxilla and mandible. (f) The 34-month postoperative periapical follow-up radiographs of both the maxillary and mandibular All-on-Four implants.

Figure 4.

(a) Preoperative cone beam computed tomography (CBCT) scan showing a severe degree of protrusion in both the maxillary and mandibular arch. (b) Preoperative clinical view showing protrusion of anterior teeth. (c) Preoperative clinical view demonstrating the deterioration of the patient's dentition. (d) Immediate postoperative panoramic view of the CBCT scan demonstrating the maxillary and mandibular implants in position. (e) Postoperative follow-up demonstrating the definitive fixed implant bridge with the lips in a relaxed position. (f) Postoperative clinical view of the fixed implant bridge for both the maxilla and mandible. (g) Twelve-month postoperative periapical radiographs of the maxillary and mandibular implants illustrate the excellent bone-level maintenance.

Figure 4.

(a) Preoperative cone beam computed tomography (CBCT) scan showing a severe degree of protrusion in both the maxillary and mandibular arch. (b) Preoperative clinical view showing protrusion of anterior teeth. (c) Preoperative clinical view demonstrating the deterioration of the patient's dentition. (d) Immediate postoperative panoramic view of the CBCT scan demonstrating the maxillary and mandibular implants in position. (e) Postoperative follow-up demonstrating the definitive fixed implant bridge with the lips in a relaxed position. (f) Postoperative clinical view of the fixed implant bridge for both the maxilla and mandible. (g) Twelve-month postoperative periapical radiographs of the maxillary and mandibular implants illustrate the excellent bone-level maintenance.

When patients who had received treatment with the All-on-Four concept returned for a follow-up appointment, they were asked if they would be willing to complete a 20-question survey of their opinion of the treatment experience. Each patient was asked if he or she would complete the questionnaire before leaving the dental office. All patients were informed that their responses would be anonymous. No record of their participation in the survey would be made. The center staff and questionnaire compilers would have no idea how any individual patient responded to any question.

Every effort was made to communicate that participation in the survey was voluntary. Once 250 patients had completed the survey, data collection ended.

Results

Respondents were 43% male and 57% female. The maxillary jaw was the most common treatment site (55%), with 33% of the respondents receiving treatment in the mandible, and 12% receiving treatment in both jaws.

Considerable variation existed among the respondents' presurgical conditions, with 5% missing only 1 tooth, 15% missing 2–3 teeth, 48% missing 4 or more but having 1 or more teeth present in at least one arch, and 23% missing all teeth in at least 1 arch. (Approximately 8% of the respondents were not sure or provided contradictory responses.)

The responses revealed high levels of satisfaction with treatment. Of respondents, 75% rated their postsurgical discomfort as being less than expected, a total of 70% reported less swelling than expected, and 95% described themselves as being either “extremely satisfied” (74%) or “satisfied” (21%) with their new teeth. Of respondents, 98% stated that they “would definitely recommend” similar treatment to a friend or colleague (88%) or would consider doing so (10%). In response to the question about the fee for treatment, 65% of the respondents stated that the fee was “much more” (28%) or “slightly more” (27%) than they had expected. Despite this, these patients proceeded with treatment. In retrospect, 49% of the respondents judged the fee to be either “definitely worth the expense” (34%) or “fair” (15%).

Patients generally provided favorable ratings to their experiences with the provisional and definitive prostheses. Approximately 60% reported better chewing, and 32% reported better speaking capabilities with the temporary prosthesis than they experienced preoperatively.

Discussion

For all the research that has focused on the biologic success or failure of osseointegrated dental implants, few studies have addressed patient perceptions of treatment outcomes.23,24  Nonetheless, some researchers have suggested that the judgment of treatment success should be rendered by individual patients, rather than via traditional clinical evaluation methods,25  as predetermined treatment-assessment criteria do not necessarily consider patients' requirements and attitudes.26 

To evaluate treatment outcomes and impact on quality of life, a number of authors have advocated the use of patient-based health-status assessments.27,28  One of the most commonly used tools for obtaining such assessments is the OHIP.14  Originally developed in Australia (in English), it includes 49 questions grouped into 7 subgroups that are based on a conceptual framework inspired by the World Health Organization International Classification of Impairments, Disabilities, and Handicaps.29  Shorter versions of the OHIP (the 14-question OHIP-1415 and the 19-question OHIP-EDENT16) have been developed, along with other assessment measures. However, among the criticisms of these measures is that the length of the original OHIP makes it too cumbersome to administer in clinical trial situations, while shorter versions may not measure enough.16  Moreover, existing measures, for the most part, have looked broadly at oral health, rather than focus on specific therapeutic interventions.

The EPIQ survey reported upon in this article, while developed for the specific purpose of evaluating the All-on-Four concept as delivered by ClearChoice Dental Implant Centers, could readily be applied to the evaluation of other therapeutic treatment. The ease of administration offers the promise of insight into a treatment dimension (patient satisfaction) that may have both theoretical and practical value. The author believes that 2 elements in the survey administration were crucial to obtaining the high response rate: the promise of respondent anonymity and the request that all surveys be completed in the dental implant center.

Conclusions

Based upon a written assessment in which 250 patients responded to 20 self-administered multiple-choice questions about comfort, function, speech, and other factors, the following conclusions were made. It was possible to obtain a large number of responses in a relatively short time (8 months), possibly because patients were asked to complete the survey anonymously before leaving the dental office. The survey data provided evidence of high patient satisfaction and improved quality of life after treatment with full-arch implant-supported, immediately loaded, fixed dental prostheses supported by NobelActive implants and delivered using the All-on-Four concept. A majority of patients expressed a willingness to recommend this treatment to others.

Figure 1.

Continued.

Figure 1.

Continued.

Figure 1.

Continued.

Figure 1.

Continued.

Figure 3.

(a) Preoperative panoramic radiograph. (b) Preoperative clinical frontal view of the patient's deteriorated dentition. (c) The immediate postoperative panoramic view of cone beam computed tomography scan of the maxillary and mandibular All-on-Four implants in position. (d) Postoperative follow-up clinical photograph of the fixed implant bridge from a frontal view in both the maxilla and mandible. (e) Postoperative periapical radiographs demonstrating the 13th month bone level around the maxillary implants. (f) Postoperative periapical radiographs demonstrating the 13th month bone level around the mandibular implants. Note the superb bone level.

Figure 3.

(a) Preoperative panoramic radiograph. (b) Preoperative clinical frontal view of the patient's deteriorated dentition. (c) The immediate postoperative panoramic view of cone beam computed tomography scan of the maxillary and mandibular All-on-Four implants in position. (d) Postoperative follow-up clinical photograph of the fixed implant bridge from a frontal view in both the maxilla and mandible. (e) Postoperative periapical radiographs demonstrating the 13th month bone level around the maxillary implants. (f) Postoperative periapical radiographs demonstrating the 13th month bone level around the mandibular implants. Note the superb bone level.

Figure 4.

Continued.

Figure 4.

Continued.

Abbreviations

     
  • EPIQ

    Edentulous Patient Impact Quotient

  •  
  • OHIP

    Oral Health Impact Profile

References

References
1.
Branemark
PI
,
Hansson
BO
,
Adell
R
,
et al
.
Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year-period
.
Scand J Plast Reconstr Surg Suppl
.
1977
;
16
:
1
132
.
2.
Adell
R
,
Lekholm
U
,
Rockler
B
,
Branemark
PI. A
15-year study of osseointegrated implants in the treatment of the edentulous jaw
.
Int J Oral Surg
.
1981;
10
:
387
416
.
3.
Szmukler-Moncler
S
,
Piattelli
A
,
Favero
GA
,
Dubruille
JH
.
Considerations preliminary to the application of early and immediate loading protocols in dental implantology
.
Clin Oral Implants Res
.
2000
;
11
:
12
25
.
4.
Aparicio
C
,
Rangert
B
,
Sennerby
L
.
Immediate/early loading of dental implants: a report from the Sociedad Española de Implantes World Congress consensus meeting in Barcelona, Spain, 2002
.
Clin Implant Dent Relat Res
.
2003
;
5
:
57
60
.
5.
Attard
NJ
,
Zarb
GA
.
Immediate and early implant loading protocols: a literature review of clinical studies
.
J Prosthet Dent
.
2005
;
94
:
242
258
.
6.
Schnitman
PA
,
Wöhrle
PS
,
Rubenstein
JE
.
Immediate fixed interim prosthesis supported by two-stage threaded implants: methodology and results
.
J Oral Implantol
.
1990
;
2
:
96
105
.
7.
Ioannidou
E
,
Doufex
A
.
Does loading time affect implant survival? A metanalysis of 1,266 implants
.
J Periodontol
.
2005
;
76
:
1252
1258
.
8.
Attard
NJ
,
Zarb
GA
.
Immediate and early implant loading protocols: a literature review of clinical studies
.
J Prosthet Dent
.
2005
;
3
:
242
258
.
9.
Nkenke
E
,
Fenner
M
.
Indications for immediate loading of implants and implant success
.
Clin Oral Impl Res
.
2006
;
17
(
suppl 2
):
19
34
.
10.
Avila
G
,
Galindo
P
,
Rios
H
,
Wang
HL
.
Immediate implant loading: current status from available literature
.
Implant Dent
.
2007
;
16
:
235
245
.
11.
Sennerby
L
,
Gottlow
J
.
Clinical outcomes of immediate/early loading of dental implants. A literature review of recent controlled prospective clinical studies
.
Aust Dent J
.
2008
;
53
(
suppl 1
):
S82
S88
.
12.
Babbush
CA
,
Kent
JN
,
Misiek
DJ
.
Titanium plasma-sprayed (TPS) screw implants for reconstruction of the edentulous mandible
.
J Oral Maxillofac Surg
.
1986
;
44
:
274
282
.
13.
Atchison
KA
,
Dolan
TA
.
Development of the Geriatric Oral Health Assessment Index
.
J Dent Educ
.
1990
;
54
:
680
687
.
14.
Slade
GD
,
Spencer
AJ
.
Development and evaluation of the Oral Health Impact Profile
.
Community Dent Health
.
1994
;
11
:
3
11
.
15.
Slade
GD
.
Derivation and validation of a short-form oral health impact profile
.
J Community Dent Oral Epidemiol
.
1997
;
25
:
284
290
.
16.
Allen
F
,
Locker
D
.
A modified short version of the Oral Health Impact Profile for assessing health-related quality of life in edentulous adults
.
Int J Prosthodont
.
2002
;
15
:
446
450
.
17.
Strauss
RP
,
Hunt
RJ
.
Understanding the value of teeth to older adults: influences on the quality of life
.
J Am Dent Assoc
.
1993
;
124
:
105
110
.
18.
Maló
P
,
Rangert
B
,
Nobre
M
.
“All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study
.
Clin Implant Dent Relat Res
.
2003;
5
(
suppl 1
):
S2
S9
.
19.
Maló
P
,
Lopez
I
,
Nobre
M
.
The All-on-Four concept
.
In
:
Babbush
C
,
Hahn
J
,
Krauser
J
,
eds
.
Dental Implants: The Art and Science. 2nd ed
.
St Louis, Mo
:
Saunders Elsevier Inc;
2010
:
435
.
20.
Maló
P
,
Rangert
B
,
Nobre
M
.
All-on-4 immediate-function concept with Branemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study
.
Clin Implant Dent Relat Res
.
2005
;(
7
suppl 1)
:
S88
–S
94
.
21.
Babbush
CA
,
Kutsko
G
,
Brokloff
J
.
The all-on-four immediate function treatment concept with Nobel Active implants: a retrospective study
.
J Oral Implantol
.
2011;
37
:
431
445
.
22.
Maló P de Araujo Nobre M, Lopes A, Moss SM, Molina GJ
.
A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up
.
J Am Dent Assoc
.
2011;
142
;
310
320
.
23.
Zani
SR
,
Rivaldo
EG
,
Frasca
LCF
,
Caye
LF
.
Oral health impact profile and prosthetic condition in edentulous patients rehabilitated with implant-supported overdentures and fixed prostheses
.
J Oral Sci
.
2009
;
51
:
535
543
.
24.
Locker
D
.
Patient-based assessment of the outcomes of implant therapy: a review of the literature
.
Int J Prosthodont
.
1998
;
11
:
453
461
.
25.
Feine
JS
,
Awad
MA
,
Lund
JP
.
The impact of patient preference on the design and interpretation of clinical trials
.
Community Dent Oral Epidemiol
.
1998
;
26
:
70
74
.
26.
Stephens
RJ
,
Hopwood
P
,
Girling
DJ
,
Machin
D
.
Randomized trials with quality of life endpoints: are doctors' ratings of patients' physical symptoms interchangeable with patients' self-ratings?
Qual Life Res
.
1997
;
6
:
225
236
.
27.
Guyat
GH
,
Feeny
D
,
Patrick
DL
.
Measuring health-related quality of life
.
Ann Intern Med
.
1993
;
118
:
622
629
.
28.
Ware
JE
,
Sherbourne
DC
.
The MOS 36-item short-form health survey (SF36). I. Conceptual framework and item select ion
.
Med Care
.
1992
;
30
:
473
483
.
29.
Locker
D
.
Measuring oral health: a conceptual framework
.
Community Dent Health
.
1988
;
5
:
3
18
.