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European Journal of Prosthodontics and Restorative Dentistry (2017) 25, 1–7
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ARTICLE IN PRESS
•••••••••••••••••••••••••••••••• EJPRD
Efficacy of Removable
Partial Denture Treatment:
A Retrospective Oral Health-
Related Quality of Life
Evaluation
ABSTRACT
Successful removable partial dentures (RPDs) use may be influenced by patient and den-
ture variables including age, denture experience and number or position of teeth being re-
placed. Influence of patient and denture variables on OHRQoL with RPDs was investigated
using ordinal logistic regression analysis. Methods: Participants provided with RPDs were
invited to complete OHIP-20 at least 4 weeks after dentures were fitted. Clinical records
were retrieved to identify a number of independent variables. Variables meeting a standard
of statistical significance were included into regression analysis to quantify influence on
OHIP-20 scores. Results: 84 patients agreed to participate. No. of missing teeth, age, gen-
der, replacement of anterior teeth and framework material were entered into the model,
which was statistically significant, p<0.001, with pseudo R2 of 0.39. Significant variables
were age (p<0.05), no. of missing teeth (p<0.01), gender (p<0.05) and replacement of an-
terior teeth (p<0.001). Replacing anterior teeth showed 9.68 point reduction in OHIP-20
score in patients with replaced anterior teeth. Discussion: Replacing anterior teeth was as-
sociated better post-operative OHRQoL outcomes, suggesting RPDs address impacts on
OHRQoL of missing anterior teeth. Success of RPDs in overcoming impacts of tooth loss
on OHRQoL was worse as more teeth were lost.
INTRODUCTION
The success of removable partial dentures (RPDs), both at an individual
and societal level, is variable and dicult to measure.1 Patient satisfaction
with removable partial dentures can be rather variable, though studies
indicate a majority of patients expressing satisfaction, signicant numbers
do report dissatisfaction and avoidance of wearing an RPD.2,3 Both patient
and denture variables may be strong determinants of success. Examina-
tion of the relationship of denture quality to patient satisfaction has dem-
onstrated some patients nd RPDs that are t for purpose clinically di-
cult to tolerate, whilst others may nd dentures satisfactory on a personal
level, whilst clinically they may be considered sub-optimal, and no particu-
lar ‘standards’ of removable partial denture construction are related to
patient satisfaction.4 The interplay between patient variables and denture
variables may have a role to play on changes to oral health-related quality
of life (OHRQoL); with some variables being more inuential on success
than others. It is not known which variables are most important, across
Keywords
Removable Partial Denture
Oral Health Related Quality Of Life
Partially Edentulous
Person-Centered Outcomes
Authors
Zaid Ali *
(PostNominalLetters)
Prof. Sarah Baker §
(PostNominalLetters)
poyan Barabari §
(PostNominalLetters)
Prof. Nicolas Martin §
(PostNominalLetters)
Address for Correspondence
Zaid Ali *
Email: ali.zaid283@gmail.com
* University of Sheeld, Charles Cliord Dental
Hospital
§
University of Sheeld
Received: 02.02.2017
Accepted: 03.02.2017
doi: 10.1922/EJPRD_01669Ali07
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European Journal of Prosthodontics and Restorative Dentistry (2017) 25 ARTICLE IN PRESS
••••••••••• Ecacy of Removable Partial Denture Treatment: A Retrospective Oral Health-Related...
the population of partially dentate patients requiring RPDs,
though it has been reported that patients are more likely to
wear an RPD if it replaces missing anterior teeth.2 The num-
ber of variables to consider is signicant with patient variables
including psychological acceptance, adaptation capacity, oral
and dental status.4,5 Denture variables include the number,
position and size of edentate saddles and variables associ-
ated with the design and manufacturing of the prostheses, in-
cluding the type of materials, derivation of support, numbers
of teeth used for support etc.6 The relative impact of these
denture and patient variables on success with RPDs has been
measured using measures of success such as continued den-
ture use and measures of satisfaction, but not using objective,
validated measures of OHRQoL as the outcome measure.2,4,6,7
A number of specic objective markers of success for the
assessment of RPDs have been developed, that include meas-
ures of masticatory eciency, patient satisfaction, continued
use of prostheses and subjective assessment against various
success criteria judged by specialists in the eld.2,4,6,7 Studies
using these have considered the relative effects of patient and
denture variables on success measured against these surro-
gate markers. In this respect, denture success, as a measure
of patient and denture variables, have been studied retro-
spectively in several studies, which have looked at continued
use of the denture and clinical acceptability.6-8 None, however,
have fully explored the effect of these variables on OHRQoL in
RPD wearers. OHRQoL seeks to evaluate the physical, psycho-
logical, and social impact of oral conditions on an individual.9
This has been described by Locker in 1988 as a construct used
to quantify the positive and negative effects of oral symptoms
on patient’s quality of life.10 The effects on this construct can
be measured through Patient Reported Outcome Measures
(PROMs) that have been specically developed and validat-
ed. Validated PROMs offer a reliable means of quantifying
OHRQoL such that differences between patient and denture
variables may be quantied and their inuence on outcome
compared. Ultimately, as the purpose of providing a RPD is
to restore function and aesthetics to overcome the impact of
tooth loss.11 Rehabilitation with a removable partial denture
has been shown to improve an individual’s quality of life and it
is by overcoming the impairment of tooth loss, restoring func-
tional ability and thereby reducing the consequent disability,
that improvements in OHRQol are made and it is therefore
logical to focus on outcome measures such as OHRQoL.12 The
choice of measure is an important one and should be consid-
ered in the context of the purpose of analysis, the population
being studied and the audience being asked to interpret the
results.13 In this case, a tool designed and validated for use in
partially dentate patients, used in the context of measuring
OHRQoL over periods of follow-up anticipated in this cohort
of patients, with items that would be expected to have im-
pacts in denture wearers would be considered to be an ap-
propriate tool and a representative measure of success from
a patient perspective.13
Disease specic measure of OHRQoL such as the Oral Health
Impact Prole, have been validated to evaluate the range
of domains that describe OHRQoL. The OHIP-20, a 20-item
subscale of the original OHIP-49 has been validated for the
measurement of OHRQoL in patients with xed and remov-
able prostheses.14 Studies that have measured success with
RPDs have identied that factors such as the type of support
derived for the denture, the framework material, whether
or not the denture replaced anterior teeth etc., play a role
in the patient’s experience with and continued use of RPDs.2
Mandibular Kennedy Class 1 dentures, i.e. those replacing
posterior teeth in bilateral free-end saddles, were often not
worn and patients with a shortened dental arch are reported
to only perceive benets of an RPD when anterior teeth are
being replaced.6,15 Neither of these studies however has in-
vestigated the relative impact of these important patient and
denture variables on a validated measure of OHRQoL such as
the OHIP.
The concept of minimum clinically important differences
(MCID) in OHRQoL is another important feature of PROMs;
dened as the smallest change in an outcome that a patient
would identify as important.16 The calculation of the MCID has
been reported by Allen
et al
. that investigated the MCID for
the OHIP-20 using the anchor-based method and determined
that a MCID for the OHIP-20 was 7 to 8 point scores.12,16
Patient and denture variables are not the only factors likely
to modify OHRQoL. Scores from PROMs may be modied by a
person’s characteristics, their social status, family and cultural
circumstances, and of course by their experience of disease
whether due to environmental (e.g. caries) or genetic causes
(e.g. congenital absence of teeth); both in terms of extent and
severity.8 It would not be feasible for clinicians to take account
of all these variables in an attempt to predict a successful out-
come with RPDs. However, there are a number of variables
which can be considered and, if their relative effects could be
quantied, could help clinicians predict which cases are more
or less likely than others to be perceived by patients as suc-
cessful.
Given that both patient and denture variables play a role in
the success outcomes, it is appropriate to undertake a study
that seeks to control some of these parameters and in this
way obtain data that is more representative of the wearing of
a denture that is ‘t for purpose’. In particular, it is the process
of denture fabrication that can be a signicant confounder in
this type of study given the high levels of quality variability as-
sociated with both the clinical and technological aspects (de-
sign and manufacturing) of denture fabrication.17,18 The levels
of scrutiny to each aspect of treatment planning and denture
design and fabrication at a Dental Teaching Hospital provides
a setting with a carefully controlled production process with
strong quality assurance protocols used for all clinical and
technological stages of denture production.
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EJPRD
The aim of this retrospective evaluation was to explore the
impact of various independent patient and denture variables
associated with the provision of RPD treatment on OHRQoL
outcomes and to test the construct validity of our chosen per-
son centered outcome measure, the OHIP-20, in the context
of RPD provision in a dental teaching hospital.
METHODS
Patients provided with an RPD from the 1st April 2014 un-
til the 1st December 2014, were identied from an electronic
database kept at the Removable Prosthodontic Laboratory
at a large UK Dental Hospital. These patients were contacted
by mailshot, which included a participant information leaet,
a questionnaire including the OHIP-20 as well as questions
concerning continued use of the RPD and a free-text box for
additional comments. The OHIP-20 is a 20-item questionnaire
measured on a 5-point Likert scale, scoring from never (0,
least impact) to very often (4, greatest impact), giving a range
of total score from 0 to 80 points. Questionnaires were indi-
vidually coded and a stamped addressed envelope was en-
closed for return of the questionnaires. Three questionnaires
were sent to participants and returns were accepted within a
4-month period between 5th January and 1st May 2015.
The following patient and denture variables were recoded
from clinical and laboratory records for those patients who
returned completed questionnaires: age, gender, number of
missing teeth (excluding third molars), denture congura-
tion (complete denture against partial denture, partial den-
ture against partial denture, partial denture against dentate
arch), type of framework support material (tooth-and-mucosa
supported Cobalt-Chromium RPDs only, mucosa supported
acrylic dentures only, combined, i.e. each arch restored with
a different style), replacement of anterior teeth, presence of a
free-end saddle, patient experience of denture wearing.
STATISTICAL ANALYSIS
The Kolmogrov-Smirnov test was used to investigate normality
of the outcome data and due to the skewed nature of the OHIP-
20 total score, non-parametric tests were used in the analysis.
Independent variables were investigated to determine if they
could be entered into a multi-variate regression analysis. Corre-
lations between OHIP-20 and skewed variables, namely, number
of missing teeth and age, were measured using Kendal’s tau cor-
relation coecient. Binary categorical variables: gender, previ-
ous denture usage, replacement of anterior teeth and presence
of a free-end saddle were analysed using a Mann Whitney U test.
Nominal variables for denture conguration and framework
materials used were tested using a Kruskal Wallis ANOVA. The
threshold for inclusion in the model was be set at p<0.219. For
each variable a minimum of 10 responses were be required as
a sucient sample to undertake multi-variate regression analy-
sis, therefore on the assumption that all variables are included
into the multivariate linear regression model a minimum of 100
responses would be required.
19
Due to the skewed nature of the
OHIP-20 total score this was transformed on a log
10
scale before
regression analysis. A pseudo R2 was calculated by entering vari-
ables that met the threshold for inclusion into an ordinal logistic
regression analysis.
Internal consistency of the OHIP-20 scale was investigated us-
ing a Cronbach’s alpha statistic. External validity was investigated
by investigating the relationship between the OHIP-20 score and
the continued use of the RPD provided, a commonly reported
positive predictor of a successful outcome with RPDs.
RESULTS
One hundred and twenty patients were identied from the
dental laboratory database and were sent questionnaires. All
patients had worn their dentures for a minimum of 4 weeks in
line with previous studies measuring effects of RPD treatment on
OHRQoL. Eighty-four completed questionnaires were collected
representing a response rate of 70%. Questionnaires of those
patients who responded were complete and there was therefore
no missing outcome data.
Descriptive data for patient and denture variables of those pa-
tients who returned completed questionnaires are presented in
Table 1. Ages ranged from 26 to 93 years, though the mean was
skewed towards older patients at 65.8 years (SD = 13.4 years).
There were 12% more male responses than females. Three quar-
ters of participants had already had experience of denture wear.
Most RPDs, 64%, were made using a tooth-and-mucosa support-
ed cobalt chromium framework, with only 27% being acrylic mu-
cosa borne RPDs. 8% of participants received a chrome denture
in one arch and an acrylic denture in the opposing arch.
Internal consistency of OHIP-20 was measured using a Cron-
bach’s alpha statistic. Including all items of the OHIP-20 gave an
alpha statistic of 0.97. The Cronbach’s alpha was also measured
for the scale if each item was removed and did not show a sig-
nicant reduction upon removal of any one of the scale items,
which indicates excellent internal consistency of the scale used.
Patients who were still using their dentures had median OHIP-20
scores of 18 compared to 27 for those wearing only one of the
dentures provided and 46 for patients not wearing any dentures
provided. This difference was not statistically signicant p=0.098.
Only three patients were not wearing either dentures provided
representing a failure rate of 3.6%. 70 patients were wearing all
of the dentures provided representing total success in 83.33%,
the remaining 11 patients, 13.1%, were provided with two den-
tures but only wore one of them.
Kilmogorov-Smirnov test for normality of the OHIP-20 score
conrmed a non-normal distribution (p<0.001), which is not unu-
sual when using quality of life measures.
Kendal’s tau correlation coecient for OHIP-20 against miss-
ing teeth and age are shown in Table 2. Gender, previous den-
ture usage, replacement of anterior teeth and presence of a
free-end saddle were analysed using a Mann Whitney U test.
Denture conguration and framework materials used were
tested using a Kruskal Wallis ANOVA. Table 2 also shows the
median OHIP-20 scores for each of these groups with the re-
spective p-values for differences between groups.
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The variables which were signicant to include in the regres-
sion were number of missing teeth, age, gender, replacement
of anterior teeth and framework material. Ordinal logistic
regression analysis (OHIP-20 score as the outcome) was per-
formed to test the model and was found to be statistically sig-
nicant, p<0.001, with a pseudo R2 of 0.39. Independent vari-
ables within the model were age (p<0.05), number of missing
teeth (p<0.01), gender (p<0.05) and whether anterior teeth
were replaced (p<0.001). Ordered log odds regression coe-
cients were transformed using the exponential to arrive at re-
gression coecients for statistically signicant variables. For
age the co-ecient was 0.97 (this relationship was negative),
for gender it was 2.45, for missing teeth the co-ecient was
1.10 and for replacement of anterior teeth the co-ecient was
9.68. Figure 1 shows a box and whisker plot of OHIP-20 total
score against whether anterior teeth were replaced or not.
1. Figures
Figure 1 Box and whisker plot representing median, inter-quartile range
and range for OHIP-20 total score, according to whether anterior
teeth were replaced or not.
Figure 1: Box and whisker plot representing median, inter-
quartile range and range for OHIP-20 total score, according to
whether anterior teeth were replaced or not.
Table 1. Descriptive data for patient and denture variables
n = Range Mean S.D.
Age (years) 26 – 93 66 13
Gender
Female 37 (44%)
Male 47 (56%)
No. missing teeth (excluding 3rd molars) 3 – 23 13 6
No. missing teeth in mandible 2 - 16 8 3
No. missing teeth in maxilla 2 - 16 9 4
Previously wore a denture?
No 21 (25%)
Yes 63 (75%)
Denture conguration
RPD vs RPD 39 (46%)
Complete denture vs RPD 16 (19%)
RPD vs Dentate/Fixed 29 (35%)
Framework material
Acrylic 23 (27%)
Chrome 54 (64%)
Both 7 (8%)
Replacement of anterior
teeth by removable denture
No 28 (33%)
Yes 56 (67%)
Free end saddle
No 23 (27%)
Yes 61 (73%)
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DISCUSSION
This was the rst evaluation of the inuence of patient and den-
ture variables on success of RPDs in the rehabilitation of tooth
loss as measured by OHRQoL. Previous studies have measured
the inuence of patient and denture variables on the success in
terms of continued denture usage and patient satisfaction.
2,20
The
data provides additional evidence that the use of OHIP-20 is a valid
measure for the construct of OHRQoL in partially dentate patients.
Internal consistency of the OHIP-20 was found to be excellent.
The Cronbach’s alpha remained strong even when items were re-
moved. External validity was good with higher OHIP-20 total score
in patients who continued to wear their dentures. Response rate
was excellent considering the use of postal questionnaires.
The most signicant variable having an effect on OHRQoL
was that of whether anterior teeth were being replaced by
the prostheses. This was negatively correlated with OHIP-20
score, which suggests that where anterior teeth are replaced,
the OHIP-20 score is reduced, i.e. there is better OHRQoL.
Where anterior teeth were replaced patients had a 33-point
improved median OHIP-20 score. There are several possible
reasons for this. Firstly, where anterior teeth are being re-
placed in a partial denture, it is quite likely that on each side
of the missing teeth space, there will be natural teeth to sup-
port the prosthesis and give greater stability and retention of
the denture by means of clasping arms and supporting rests.
Secondly, where patients have missing anterior teeth, it is
likely that these spaces are visible to other people, which the
patient in question may be particularly conscious of in their
interactions socially and intimately. It is understandable that
these impacts would be improved by the provision of pros-
theses.
The second important variable was found to be the number
of missing teeth, which was positively correlated such that, as
number of missing teeth increases so does the OHIP-20 score.
It is understandable that as the number of teeth increases the
number and degree of impacts on OHRQoL will increase. It
is worth noting that whilst one additional missing tooth only
changes OHIP-20 scores by 1.1 points, a loss of six or seven
teeth would have a magnitude of impact of the order asso-
ciated with a clinically meaningful difference to patients, the
MCID (minimum clinically important difference).
Age and gender were also signicantly related to the OHIP-20
score with females demonstrating a reduced OHRQoL meas-
ured by 2.45 points on the OHIP-20 scale. Whilst this is statis-
tically signicant it would not meet the threshold for clinical
meaningfulness to a patient measured by the MCID. Age on
the other hand was found to be related to OHRQoL, with an
increase in OHRQoL, measured as a reduction by 0.97 OHIP-
20 points for each additional year. As such we may argue that
every seven to eight additional years of life improves OHRQoL
by the MCID, a phenomenon, which is dicult to explain from
this study. Social handicap is an important domain measured
by the OHIP, which may in some part describe this interest-
ing nding. Social handicap is be shaped by the individual’s
expectations, which, as with all components of quality of life,
is informed by the “individual’s perceptions of their position
in life in the context of culture and value systems… in rela-
tion to their goals, expectations, standards and concerns”.13,21
Could it be the case that as patients age their expectations
and standards change in respect of social-life, and perhaps
even in respect to other domains such as functional status?
Previous literature, however, does shed some light on this
with Steele
et al
. comparing samples from the UK Adult Den-
tal Health Survey 1998 with the Australian National Dental
Telephone Interview Survey of 1999, using the OHIP-14 as a
measure of OHRQoL, found the ‘impact of oral health prob-
lems reduces with age’, p<0.00122. This phenomenon has
been demonstrated in other studies22-25. It is suggested that
the lower impacts on older persons may not be entirely age-
related per se, but rather that effects are ‘cohort dependent’.
Table 2. Denture and patient-related variables and OHRQoL
Variable Group
Median
OHIP-20
score
p-value
Gender
Male 16
0.18*
Female 24
Previous
Denture Usage
Yes 19
0.43
No 26
Replacement
of Anterior
Teeth
Yes 14
<0.001*
No 47
Presence of
a Free-end
Saddle
Yes 20
0.64
No 18
Framework
material
Chrome Only 19
0.15*Acrylic Only 34
Both 12
Denture
conguration
RPD vs RPD 21
0.91
RPD vs CD 20
RPD vs
Dentate 20
Variable Correlation
coecient p-value
Age - 0.11 0.15*
Total number of missing
teeth (excluding
third molars)
0.18 <0.05*
* Indicates p values deemed appropriate for inclusion in multi-
variate linear regression analysis
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That is to say that patients in older age groups age socially
different to persons in younger age groups and their levels
of health-expectations set at a different threshold, and that
these relationships may change as people in older age brack-
ets approach expectations to healthcare with different expec-
tations in the future.22,23
Patients who were still using their dentures had median
OHIP-20 scores of 18 points compared to 27 points for those
wearing only one of the dentures provided and 46 for patients
not wearing any dentures provided, giving a correlation coe-
cient of ρ = 0.182. This co-ecient was not statistically signi-
cant, p = 0.098, however, with only three patients not wearing
any of the dentures provided there were too few to make a
reliable comparison.
Participants in this study have been selected from a data-
base of patients treated in a teaching dental hospital with
strong clinical and technological quality assured protocols
and processes. This reduces the potential impact of the vari-
ability in quality of denture fabrication and enables the study
to focus on the patients’ true denture wearing experience
with the knowledge that all dentures were t for purpose. The
participating patients ranged from varying degrees of clinical
complexity, as they included those managed and treated on
undergraduate, postgraduate and specialist clinics, in accord-
ance with their needs and expectations. Participants included
in this study may therefore be considered to be representa-
tive of the population in general as they are likely to include
patients at all levels of complexity. In this sense, we can con-
sider that this retrospective evaluation is testing the ecacy
of RPDs as we have carefully controlled a signicant variable
and potential confounder; the quality of the RPD. The use of
postal questionnaires, however, may have introduced selec-
tion bias, excluding some participants who had barriers to
completion and returning these forms.
Clearly the retrospective nature of this study has limitations.
It was not possible to measure the magnitude of change is
OHRQoL in the absence of a pre-treatment score. Indeed
change scores would be just as useful in evaluation of OHRQoL
impacts of RPD treatment, it could be argued more useful as
indeed it is the change score which is of greatest value in de-
termining the extent of impact therapy had had on OHRQoL.
Of interest further still would be the impact of follow-up in
terms of response shift representing either greater adapta-
tion to the removable prosthesis or perhaps gradual return
of the negative impacts of tooth loss as the RPDs age. The
current evaluation allows for the assessment of OHRQoL at a
particular time-point after treatment and whilst this does not
provide information about the change score it does enable an
assessment to be made of the impact, which various patient
and denture variables have on OHRQoL in patients recently
provided with RPDs.
Prospective evaluation would also allow standardisation of
follow-up appointments. With the range of follow-up found
in this study of anywhere between one and seven months, a
further limitation of this retrospective evaluation was in the
control over follow-up, potentially an important confound-
ing variable. A similarly designed prospective study, control-
ling for the follow-up period as well as measuring the change
score, would provide greater information about the impact of
patient and denture variables on change in OHRQoL as well
as giving greater control of potential bias introduced by phe-
nomena such as response shift.
The types of dentures provided may have been different
within a dental teaching hospital compared to the provision
more generally. In this study 64.3% were provided with only
chrome dentures and 8.3% were provided with a mixture of
chrome and acrylic dentures in each arch. The provision of
laboratory work in primary care incurs a cost directly to the
prescribing practitioner and the prescription of more costly
chrome framework dentures in the general population is un-
likely to be represented by the percentages demonstrated
here. Furthermore the dentures provided in Dental Teaching
Hospitals are subject to several levels of scrutiny, which helps
to ensure a high level of care and attention. In this respect
this evaluation is one made on dentures provided within a
controlled environment to enhance the ecacy of RPD provi-
sion. Whether this can be translated to the effectiveness of
RPD provision in a more general sense is uncertain. To further
improve the generalizability of the study and consider the de-
gree of benecial effect of RPD provision under ‘real world’
conditions, and hence test the effectiveness of the interven-
tion, it would be appropriate to conduct the study in multiple
settings, including primary, secondary care and dental teach-
ing hospitals or other care settings.
With regards to the functional limitations caused by missing
anterior teeth, it is likely to be more dicult, where anterior
teeth are missing, to function with either no dentures or an
ill-tting and unstable prosthesis and so items concerned with
food catching or diculty chewing would be affected in such
patients, as well as avoidance of some foods or unsatisfac-
tory diets.26 Where anterior teeth are all present it is less likely
that a patient will have diculty incising into foods and may
even have learnt to undertake other masticatory functions
using anterior teeth, furthermore the masticatory eciency
may be inuenced by aesthetics.3,27,28 The work of Kayser
et al
demonstrates that where anterior teeth are present, though
there are missing occlusal units, social functions related to
aesthetics and phonetics were given greater importance by
patients.5,28
In conclusion, this retrospective cohort study investigating
the factors impacting on one to seven month post-treatment
OHRQoL outcomes in patients provided with RPDs for the re-
placement of missing teeth, has shown that:
Replacement of anterior teeth is associated with improved
OHRQoL outcomes. The clinical signicance of this effect is
over the level of minimal clinically important difference.
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EJPRD
OHRQoL is lower as more teeth are lost and as such clini-
cians should be mindful of the cumulative effect of tooth loss
on OHRQoL impacts for patients. The loss of six to seven ad-
ditional teeth demonstrates a clinically meaningful reduction
in OHRQoL.
Increased age is associated with a reduced impact of oral
diseases on OHRQoL and this had a clinically meaningful dif-
ference for every seven to eight additional years of age.
Validity of measuring OHRQoL using the OHIP-20 scale in re-
movable prosthodontics outcome research has been further
supported as it has demonstrated excellent internal consist-
ency and correlation with other variables denoting patient-
perceived success.
RPDs provided in an environment with strong clinical and
technological quality assured protocols and processes dem-
onstrate high levels of success with 96.4% continued use of
RPDs during the follow-up period.
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