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.
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.3–5 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.7–12
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.
aterials and M ethods
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.
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.18–22
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.
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.
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.
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.