Article

Quality of Life of Endodontically Treated versus Implant Treated Patients: A University-based Qualitative Research Study

Department of Endodontics, University of Washington School of Dentistry, Seattle, WA 98195-7448, USA.
Journal of endodontics (Impact Factor: 3.38). 07/2011; 37(7):903-9. DOI: 10.1016/j.joen.2011.03.026
Source: PubMed
ABSTRACT
Up-to-date studies comparing endodontic treatment versus implant-supported prosthesis have shown similar clinical outcome and survival rates. However, no data are available comparing both treatment modalities based on the patient's perception of quality of life. This study was designed to qualitatively describe and compare the quality of life of patients with restored, single endodontically treated teeth versus patients with single implant-supported fixed prostheses.
Forty-eight patients agreed to participate in the study (n = 24 from each treatment modality). Of those, 37 actually participated in the study: 17 were endodontically treated and 20 had an implant-supported prosthesis. Patients in each of the two groups were randomly selected from the Graduate Endodontics and Graduate Periodontics Departments, respectively. Six focus group discussions (n = 3 per treatment group) were held and audio-recorded for subsequent thematic analysis. Data were analyzed to identify common themes within each category and compared to assess any differences in quality of life between the two treatments. Additionally, a quality of life survey, the shortened version of the Oral Health Impact Profile (OHIP-14), was given before the discussion group and the responses analyzed.
The results obtained from this study show similar overall OHIP scores and show a high rate of satisfaction with both treatment modalities. Content analysis of the discussion groups revealed several themes and subthemes. The major themes were importance of overall health, financial implications of the treatments, perception of the treatments and its outcomes, time since treatment, and follow-up dental visits.
The results help identify patients' perception and concerns with each treatment modality and assist the clinician and patient in the selection of an optimal treatment for their given situation. In addition to the prognosis and outcomes, clinicians should consider patients' perceptions and preferences as well as the influence each therapy may have on their quality of life, both short- and long-term. Overall, all the participants in this study were pleased with the treatment received and expressed a clear message to save their natural dentition whenever possible.

Full-text

Available from: Nestor Cohenca
Quality of Life of Endodontically Treated versus
Implant Treated Patients: A University-based
Qualitative Research Study
Dustin L. Gatten, DDS,
*
Christine A. Riedy, PhD, MPH,
Sul Ki Hong, DDS,
James D. Johnson, DDS, MS,
*
and Nestor Cohenca, DDS
*
§
Abstract
Introduction: Up-to-date studies comparing
endodontic treatment versus implant-supported pros-
thesis have shown similar clinical outcome and survival
rates. However, no data are available comparing both
treatment modalities based on the patient’s perception
of quality of life. This study was designed to qualitatively
describe and compare the quality of life of patients with
restored, single endodontically treated teeth versus
patients with single implant-supported fixed prostheses.
Methods: Forty-eight patients agreed to participate in
the study (n = 24 from each treatment modality). Of
those, 37 actually participated in the study: 17 were
endodontically treated and 20 had an implant-
supported prosthesis. Patients in each of the two groups
were randomly selected from the Graduate Endodontics
and Graduate Periodontics Departments, respectively.
Six focus group discussions (n = 3 per treatment group)
were held and audio-recorded for subsequent thematic
analysis. Data were analyzed to identify common
themes within each category and compared to assess
any differences in quality of life between the two
treatments. Additionally, a quality of life survey, the
shortened version of the Oral Health Impact Profile
(OHIP-14), was given before the discussion group and
the responses analyzed. Results: The results obtained
from this study show similar overall OHIP scores and
show a high rate of satisfaction with both treatment
modalities. Content analysis of the discussion groups re-
vealed several themes and subthemes. The major
themes were importance of overall health, financial
implications of the treatments, perception of the treat-
ments and its outcomes, time since treatment, and
follow-up dental visits. Conclusions: The results help
identify patients’ perception and concerns with each
treatment modality and assist the clinician and patient
in the selection of an optimal treatment for their given
situation. In addition to the prognosis and outcomes, clinicians should consider
patients’ perceptions and preferences as well as the influence each therapy may
have on their quality of life, both short- and long-term. Overall, all the participants in
this study were pleased with the treatment received and expressed a clear message
to save their natural dentition whenever possible.
(J Endod 2011;37:903–909)
Key Words
Endodontics, implants, Oral Health Impact Profile, quality of life, root canal
I
t is now a very common occurrence for a clinician and a patient to be confronted by
the following treatment question: ‘Should a tooth be saved through root canal treat-
ment and restoration or be extracted and replaced with a single implant-based sup-
ported prosthesis?’ Every patient has a unique case prohibiting a perfect answer that
fits everyone’s situation. Although the decision-making process is critical because of
the irreversible consequence of losing a tooth, guidelines are lacking to assist the clini-
cians and patients in making an informed, evidenced-based decision (1–3).
Clinicians are ethically bound to inform patients of all reasonable treatment
options, inform them of benefits and risk factors involving available treatment options,
and obtain informed consent before initiating treatment. Clinical treatment decisions
regarding endodontic or implant therapy must always be made in the best interest of
the patient as well as be based on the best, most currently available evidence.
Several factors should be considered when treatment planning whether to perform
endodontic therapy or extract a tooth and place an implant (4). Among these are
patient-related factors (ie, systemic and oral health, esthetic demands, and comfort
and treatment perceptions), tooth- and periodontium-related factors (ie, pulpal and
periodontal conditions, restorability of the tooth, color characteristics of the teeth,
quantity and quality of bone, and soft-tissue anatomy), and treatment-related factors
(ie, cost-benefit ratio, the potential for procedural complications, required adjunctive
procedures, and treatment outcomes) (4–6).
It is also important to remember that there are multiple risk factors for both
implant and endodontic treatment. For implant treatment, risk factors include smoking,
diabetes, decreased estrogen levels in postmenopausal women, bone quantity and
quality, and use of intravenous bisphosphonates (7–14). Risk factors for
nonsurgical endodontic therapy include smoking, diabetes, apical periodontitis, and
inadequate coronal restoration (14–16). These risk factors need to be taken into
consideration when treatment planning for either treatment.
Several outcome studies have investigated both implant and endodontic therapy.
Retrospective, meta-analysis, and systematic review studies have all shown similarly
high success rates between the two treatment types (6, 17, 18). However, it is
difficult to compare the two because studies vary considerably in design, success
definition, assessment methods, operator type, and sample size (18). Outcomes of
root canal treatment are usually assessed by stringent criteria including complete heal-
ing of periapical disease and clinical function without signs or symptoms. A tooth that
has incomplete radiographic healing at the time of re-evaluation would not be
considered a success by this definition, even if it was asymptomatic and fully functional
(19, 20). Outcome criteria for implants have been primarily judged by the implants’
From the Departments of *Endodontics,
Dental Public
Health Sciences,
Periodontics, and
§
Pediatric Dentistry, Univer-
sity of Washington School of Dentistry, Seattle, Washington.
Address requests for reprints to Dr Nestor Cohenca, Depart-
ment of Endodontics, University of Washington, Box 357448,
Seattle, WA 98195-7448. E-mail address: cohenca@uw.edu
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.03.026
Clinical Research
JOE Volume 37, Number 7, July 2011 Quality of Life of Endodontically and Implant Treated Patients 903
Page 1
survival and functionality in the mouth. An implant with a draining sinus
tract would be considered surviving. This leads to the important
question, ‘Can endodontic and implant success rates really be
compared?’
Both nonsurgical root canal therapy followed by an appropriate
restoration and single-tooth implants are excellent treatment modalities
for the treatment of compromised teeth (1, 17). Although current
studies have evaluated and compared outcomes of both procedures
in a quantitative manner (ie, success rates) (6, 17, 18) and
have evaluated risk factors associated with each treatment modality
(7–15), no data are available comparing both treatment modalities
in a qualitative manner. Evaluating patients’ perceptions and the
psychosocial effect on their quality of life are likely critical to patients
and therefore should be taken into consideration by the clinician (18).
Qualitative research can provide a deeper understanding of, or
insight into, a particular problem (21). Focus group discussions are
‘interviews’ with small groups of relatively homogeneous people with
similar backgrounds and experiences. Participants are asked to reflect
on the moderators’ questions, provide their own comments, listen to
what the rest of the group has to say, and react to their observations.
The main purpose is to elicit ideas, insights, and experiences in a social
context in which people stimulate each other and consider their own
views along with the views of others (22). The results obtained from
qualitative studies help to identify and contextualize patients’ percep-
tions and concerns with each treatment modality and may assist the
clinician and patient in the selection of an optimal treatment for their
given situation. The purpose of this study was to compare the perceived
quality of life of patients who received single-tooth endodontic therapy
versus those that received single implant-supported prosthesis.
Materials and Methods
Subject Recruitment and Inclusion Criteria
Patients treated at either the Graduate Endodontic Clinic or Grad-
uate Periodontic Clinic were considered for this study. Patients’ charts
were randomly selected from the database of the respective departments
and screened for eligibility based on the predetermined criteria. No clin-
ical or radiographic examination was conducted as part of this study.
Patients were telephoned using a detailed recruitment script and
invited to participate in the study. Twenty-four patients in each treatment
modality (single-tooth nonsurgical endodontic therapy vs single
implant-supported prosthesis) were approached for participation.
Patients who were willing to participate were asked to choose one of
three focus group discussion dates. All study materials and approaches
were approved by the University Institutional Review Board. Consent
was obtained by all participants before their participation.
Inclusion criteria included the following: (1) patients who
received one root canal therapy or a single implant-based rehabilita-
tion, (2) patients with a coronal restoration with at least 1 year in
occlusal function, (3) patients whose treatment was provided by clini-
cians with the same level of proficiency (ie, graduate students in the
respective departments), (4) patients who were $18 years old, and
(5) patients who were American Society of Anesthesiology I and II.
Quality of Life Assessment (Oral Health Impact Prole)
Immediately before the focus group discussion, all participants
were asked to complete a quality of life survey, a shortened version
of the Oral Health Impact Profile (OHIP-14) (23). The OHIP measures
people’s perceptions of the social impact of oral disorders on their well-
being (24). The aim of this index is to provide a comprehensive
measure of self-reported dysfunction, discomfort, and disability arising
from oral conditions. It is based on Locker’s adaptation of the World
Health Organization’s classification of impairments, disabilities, and
handicaps (25). In the World Health Organization model, impacts
are organized linearly to move from a biological, to a behavioral, to
a social level of analysis. Slade and Spencer (24) adapted this by
proposing seven dimensions of impact of oral conditions on the
patients’ well-being (7 items within each dimension for a total of 49
items: OHIP-49). The seven dimensions include the following: func-
tional limitation, physical pain, psychological discomfort, physical
disability, psychological disability, social disability, and handicap. A
shortened version (OHIP-14) was later developed based on controlled
stepwise regression analyses that yielded a subset of 14 items (two items
within each of the seven dimensions, R
2
= 0.94) (23). The short form of
the OHIP was found to be valid (P < .05, associated with clinical oral
status and sociodemographic variables) and reliable (Cronbach alpha
= 0.88). Each item is scored on a five-point scale ranging from ‘never’
(coded 0) to ‘very often’ (coded 4). Table 1 lists the OHIP-14
dimensions and individual items.
Focus Group Discussions
A semistructured discussion guide was constructed and used by
the moderator during the focus groups. The guide included questions
related to oral health quality of life, perception of oral health/teeth in
general, and treatment experiences (Table 2). The same moderator
and comoderator conducted all three discussion groups. The discus-
sions were audio-recorded for data-analysis purposes using a digital
recorder. The discussions lasted approximately 90 minutes for each
group. All participants were provided food and beverages during the
discussion and were compensated for their time and travel expenses.
TABLE 1. OHIP-14 Items
During the last year, how often have the following occurred?
1. Functional limitation
Have you had trouble pronouncing any words because of
problems with your teeth, mouth, or dentures?
Have you felt that your sense of taste has worsened because
of problems with your teeth, mouth, or dentures?
2. Physical pain
Have you had painful aching in your mouth?
Have you found it uncomfortable to eat any foods because
of problems with your teeth, mouth, or dentures?
3. Psychological discomfort
Have you been self-conscious because of your teeth, mouth,
or dentures?
Have you felt tense because of problems with your teeth,
mouth, or dentures?
4. Physical disability
Has your diet been unsatisfactory because of problems with
your teeth, mouth, or dentures?
Have you had to interrupt meals because of problems with
your teeth, mouth, or dentures?
5. Psychological disability
Have you found it difficult to relax because of problems with
your teeth, mouth, or dentures?
Have you been a bit embarrassed because of problems with
your teeth, mouth, or dentures?
6. Social disability
Have you been a bit irritable with other people because
of problems with your teeth, mouth, or dentures?
Have you had difficulty doing your usual jobs because
of problems with your teeth, mouth or dentures?
7. Handicap
Have you felt that life in general was less satisfying because
of problems with your teeth, mouth, or dentures?
Have you been totally unable to function because of
problems with your teeth, mouth, or dentures?
0 = never, 1 = hardly ever, 2 = occasionally, 3 = fairly often, and 4 = very often.
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Data Analysis
The OHIP-14 data were coded and entered into SPSS (v.16; IBM
Corp, Somers, NY) for analysis. The dependent variables were based
on the responses to the OHIP-14 made on a five-point ordinal scale
(‘‘never’ coded ‘0’’, ‘hardly ever’ coded ‘1’’, ‘occasionally’ coded
‘2’’, ‘fairly often’ coded ‘3’’, and ‘very often’ coded ‘4’’). Two vari-
ables were calculated; prevalence was defined as the percent of individ-
uals who responded ‘occasionally’ to ‘very often’ on any of the items,
and severity was defined as the sum of the ordinal values of the 14 items.
Statistical significance of the prevalence scores and the mean levels of
the severity scores between treatment groups and between sexes were
calculated using the chi-square, Fisher exact test, and Mann-Whitney
U tests, respectively. Descriptive statistics (mean and standard devia-
tion) and frequency counts were run for the items and dimensions.
The level of significance was set at alpha = .05.
Analysis of the discussion of the focus groups was transcript based.
Digital recordings of the discussions were uploaded and transcribed by
an individual unaffiliated with the study. The resulting transcripts were
reviewed for accuracy and analyzed for content. All of the transcripts
were reviewed by two individuals to establish a thematic coding scheme;
any disagreements on the themes and subthemes were discussed and
mutually resolved. Codes and subcodes were assigned for the mutually
agreed-upon identified themes and subthemes, respectively. Further-
more, other thematic categories that were identified during the coding
process were added to the coding scheme. As described by Bailey and
Jackson (26), analysis of the transcripts used a mixed-method
approach using both inductive (eg, grounded theory) and a priori
(eg, theory driven from the literature) procedures. This approach
was used because researchers inevitability bring their prior theoretical
stance or research experience to the coding process. Coding of the tran-
scripts was performed by the principal investigator (DG). A second indi-
vidual coded slightly less than 20% of the transcripts to compare
agreement. The transcripts were analyzed to identify common themes
and subthemes within the discussion groups and compared with
each type of treatment to a sufficient level of saturation. After coding
was completed, the content within each thematic code and subcode
was collated and summarized. Participants’ quotes were used to high-
light relevant themes and subthemes.
Results
Overall, there were 37 individuals who participated in the six focus
group discussions. Patients from both treatment categories were
divided into three groups based on their scheduled session. The
implant-treated groups (n = 20) included 12 women and 8 men,
whereas the endodontically treated groups (n = 17) included 12
men and 5 women. The overall mean age was 57. The implant-
treated patients included 4 anterior and 16 posterior implants. The
endodontically treated patients included 3 anterior- and 14
posterior-treated teeth.
All participants completed the entire OHIP-14 instrument before
the discussion group. All OHIP items had a majority of individuals
who responded that they never experienced the oral health-related
quality of life impact after their treatment (range across items, 60%–
94%). Figure 1 shows the percent distribution of responses across
the seven dimensions for the categories ‘occasionally’ to ‘very often.’
(Responses within each OHIP-14 item do not equal 100 because the
‘never’ and ‘hardly ever’ categories are not included). In this study,
very few individuals experienced the impacts ‘fairly often’ or ‘very
often.’ The most commonly experienced oral health-related quality
of life impacts across participants were in the dimensions of physical
pain (painful aching, 22%; uncomfortable to eat, 30%), and psycholog-
ical discomfort (self-conscious, 30%; felt tense, 22%).
The treatment groups were not significantly different across the
items. There was a significant difference in the mean severity score
(range, 0–24) between the two treatment categories (endodontic treat-
ment group mean = 7.5, implant treatment group mean = 3.8). Further
analyses examining the mean severity score within each of the seven
dimensions found a significant difference between treatment groups
in the following two of the seven dimension scores: psychological
discomfort (P = .01) and psychological disability (P = .02) scores,
with the endodontic treatment group reporting higher scores. Higher
scores indicate worse oral health-related quality of life. Upon further
investigation, when comparing male with female scores within the
endodontic treatment group, women reported a significantly higher
score in psychological disability (P = .04). The comparison between
male and female mean severity scores within the implant-treated group
revealed a significantly higher score for women in the physical disability
dimension (P = .04).
Content analysis of the discussion groups revealed commonly
mentioned participant remarks (Table 3). These data were organized
into several themes and subthemes (Table 4). The most significant
themes were importance of overall health, financial implications of
the treatments, perception of the treatments and its outcomes, time
since treatment, esthetics, functionality, and follow-up dental visits.
Importance of Overall Health
Overall, most participants in both groups either mentioned or
agreed that keeping their teeth and having a healthy smile was important
to and an indicator for their overall health. They made the connection of
their dental health to their overall health.
Keeping Teeth in General
All participants except one individual in the endodontic group felt
it was important to keep their teeth and they see it as a high priority
(97.3%). They would do whatever they could to keep their teeth.
Common statements were made such as, ‘Well, I’ll say this okay, I
want to keep every tooth I got, okay.’
TABLE 2. Discussion Guide Questions
1. Before you received your endodontic treatment or implant,
how did you feel about the importance of keeping your
own teeth?
2. Before your treatment, how often did you visit the dentist?
What was your main reason for visiting the dentist?
3. After your treatment, how often have you visited the
dentist? What has been your main reason for visiting?
4. Describe your daily life experience since having your
treatment.
5. How does your endodontically treated tooth or implant feel
compared with your other teeth?
6. How does your endodontically treated tooth or implant
affect your eating? Drinking? Does it feel different to eat
or drink now?
7. How does your endodontically treated tooth or implant
affect your appearance? How has it affected your
appearance and smile?
8. Thinking back to the procedure when you had your
endodontic treatment or implant, how would you rate
the pain? What was your level of pain after the
procedure? Currently?
9. Can you describe any issues or concerns with maintaining
your implant or endodontically treated tooth?
10. If you had to go back for maintenance, how many times
and what type of procedures were done?
11. Are you satisfied with the result of your root canal–treated
tooth or implant?
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Family/Peer Inuence
Family or peers have a strong influence on what treatment patients
elect to receive. Participants mentioned this as their reason to have
certain treatments performed or how well they took care of their teeth
at certain times in their lives. A few participants talked about family and
friends who have lost their teeth and that they are ‘paying for it now.’
This helped influence them to keep their teeth.
Oral Hygiene Prevention
Overall, most participants in both the implant and endodontic
group seem to clean their teeth better and see the dentist more often
for regular cleanings and checkups since the time of their treatment.
Financial Implications of Procedure/Cost of Treatment
The financial aspect and cost of dental treatments guides people in
their treatment decisions. Most participants in both groups felt that the
cost of their respective treatment was expensive. Many participants in
both groups chose to come to the dental school for treatment because
it was less expensive than outside the dental school. In the implant
group, a few individuals commented on the fact that when they were
younger and could not afford certain treatments, they just had teeth ex-
tracted. Later in life, finances still influence their treatment decisions,
but they are more likely to do things like get implants because they
can afford them now. The issue of cost came up as the rationale to
protect the implant or clean it better, or led to the feeling that ‘they
better hold on to it for a long time.’ The endodontic group also weighed
the financial aspect of treatment before deciding on getting endodontic
treatment and keeping a tooth.
Insurance Coverage
Whether a treatment is covered by insurance or not plays a key role
as to whether patients will get a certain dental treatment. Almost all
participants that have dental insurance in the implant group stated
that their insurance does not cover the cost of an implant. Participants
in the endodontically treated group who had insurance stated that insur-
ance covered most of the cost of their root canal and crown. Although
many in the endodontically treated group thought treatment was expen-
sive, those that had insurance said it really helped.
Additional Costs
Several participants from both groups mentioned that they were
surprised about additional costs on top of the initial price quoted to
them for their implant or root canal. Some endodontically treated
participants stated that their insurance does not cover as much of the
crown as the root canal. One individual stated, ‘The cost was a big thing
when I got into it. The crown, even with insurance.I don’t think the
root canal was that bad with our insurance but the crown portion
0 10203040
Totally unable to function
Life generally less satisfying
Difficulty doing usual jobs
A bit irritable
A bit embarrassed
Difficult to relax
Interrupts meals
Diet unsatisfactory
Felt tense
Self-conscious
Uncomfortable to eat
Painful aching
Altered sense of taste
Trouble pronouncing words
Percentage
Occasionall
y
Fairl
y
often Ver
y
often
Functional limitation
Physical pain
Psychological discomfort
Social disability
Handicap
Psychological disability
Physical disability
No responses in item category
Figure 1. The distribution (%) of responses to each of the OHIP-14 items for all participants. Note that the responses within each OHIP-14 item do not equal 100
because the ‘never’ and ‘hardly ever’ categories are not included.
TABLE 3. Commonly Mentioned Remarks within the Endodontically Treated Root Canal Therapy (RCT) Group, Implant-treated Group, and within Both Groups
RCT groups Implant groups Implant and RCT groups
Patient with preoperative pain are happy
with little or no pain during and after
treatment
Complain of having to open mouth a long
time
Surprised of less pain with procedure than
what they had heard from other people
The worst pain during treatment was
from the anesthetic injection
Follow-ups are short appointments
Peace of mind that infection is gone
Tooth feels ‘numb’’; no sensitivity to hot
or cold
No change in maintenance compared
with the other teeth
Tendency to protect the implant while
eating (ie, eat on the other side)
Difference in cleaning than other teeth
(ie, floss more, toothpicks, and so on)
Esthetics, dark area near the gums
Long time to get everything done
The worst pain from the procedure was
the extraction
Multiple appointments
Both groups feel it is important to keep
their teeth
Part of their overall health
Surprised of cost of crown on top of the
treatment
Trouble flossing because of tight contact
of new crown
Those with treatment in the anterior feel
better esthetically
Peer influence of getting respective
treatment done
Minimal pain during treatment
Patients go to the dentist more regularly
after treatment
Satisfied overall with treatment
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was just.the copay was a lot.and I only had one. I can’t imagine if
you had a lot more than that.’
Perception of Treatment and Its Outcome
Keeping the Tooth/Implant.
Most participants were very happy
with the implant treatment and its outcome. Even participants that expe-
rienced minor problems during the procedure or after including pain
were still pleased with the overall outcome.
In the endodontic group, keeping the tooth in question was
a primary reason for most of the participants to get endodontic treat-
ment as well as the reason for their satisfaction with the treatment.
All participants were happy at the overall outcome of their treatment,
even if there were mishaps along the way. It was not uncommon to
get comments like, ‘I was delighted to have that opportunity to save
the tooth.’
Physical Pain. Two participants within the implant discussion
groups said they had pain after the implant placement, after crown
placement, and still continue to have pain in the area although the
implant is functional. It seemed as though the postoperative pain the
participants described was more of a dull, nagging pain. Some partic-
ipants described their pain as coming from the bone or jaw, and
a couple of people stated that they had pain in the gingival tissue next
to the implant. Some said they also noticed some numbness in certain
areas of the mouth and face for some time after the procedure. A couple
of individuals in the endodontic discussions also commented that they
can still feel ‘sensation’ or ‘sensitivity’ at times but that it is not painful.
Physical Pain of Procedure. Although most individuals in the
implant group agree that there is only minor pain during the procedure,
an overwhelming number of participants stated that the worst pain of the
whole procedure was the extraction of the tooth before implant place-
ment. A few participants classified the pain during the procedure as
more than mild, and a couple participants mentioned postoperative
swelling. Some participants made comments about pain medications
helping reduce their pain after the procedure.
Some participants in the endodontic treatment category stated
having sensation during the procedure but no pain. Some stated having
a little pain during or after the procedure, but they said it was manage-
able. One person even stated they were surprised at the ‘lack of pain’
during the procedure. The issue came up that root canal treatment has
somewhat of a bad rap, and participants stated that they always heard
how terrible root canals were. However, they were surprised because
the procedure was tolerable.
Reduction of Prior Pain. Participants mentioned implant treat-
ment as reducing any pain experienced before the procedure. Others
in the endodontic group stated that the main reason they were happy
with the treatment was because it completely eliminated their previous
pain.
Length of Treatment
Open Mouth in Chair Process.
Within the implant groups, there
was a common complaint of how long it took to get everything
completed, including the crown placement. Most participants recall
at least a 3- to 6-month gap between the time of implant placement
and receiving their crown. Those that had bone grafts done before
the implant placement had to wait an extra 4 months after the bone graft
to get the implant. Others said they had a tooth extracted and had to wait
a few months for their site to be ready for an implant. For the actual
length of the implant placement procedure, most felt it took a long
time. Overall, the general consensus was that participants felt the overall
process took a long time. However, it seems that patients are happier
when they know what to expect beforehand.
For the endodontic groups, the most common complaint was the
length of time they had to spend with their mouth open. One participant
commented that ‘The only thing I think that I didn’t feel very comfort-
able about, you have to keep your mouth open for a while.’ Some com-
mented that if a bite block was used to help them stay open it did help,
but they were still uncomfortable. A few participants commented that
their jaw was sore or that it was hard to close after the procedure.
Another concern that came up was that the crown took a couple of
appointments after the endodontic treatment.
Time Since Treatment. The time since treatment in the implant
group varied from 1 to 6 years. The time since treatment in the endodontic
group varied from 1 to 3.5 years. Overall, the average time since treatment
was longer in the implant group than in the endodontic group.
Esthetics. Many participants got their implants in order to improve
the esthetics of their mouth and/or to keep other teeth from shifting or
moving in their mouth. In some cases in which participants were
missing a tooth or had a broken tooth in the site of the implant, they
were happy to have a ‘tooth’ again. One participant stated, ‘Well after
going around with no tooth, you’re in a position where you can talk and
smile again. It was wonderful.’ Some also said that the implant and
crown added some fullness to their face where they noticed a concavity
where their tooth was missing. Other participants said that they open
their mouth more, smile more, and feel more confident. Some partic-
ipants were positively surprised how much their implants looked like
their natural teeth.
The position of the implant in the mouth also seemed to dictate
how satisfied patients were with the esthetics of their implant. Patients
TABLE 4. Data Organized into Several Themes and Subthemes
Themes Implant groups ENDO groups
Importance of overall
oral health
Both groups felt that it was important to keep their teeth; part of their overall health.
Financial implications
of treatment
Cost of treatment is high. Insurance does
not cover implant treatment. Surprised
about the additional costs of the crown.
Cost of treatment is high. Insurance
usually covers most of the endodontic
treatment. Surprised about additional
costs of the crown.
Perception of the treatment
and its outcomes
All participants were pleased overall with the treatment received. Most felt treatment took a long
time (ie, time mouth was open and length of treatment).
Time since treatment 1–6 years 1–3.5 years
Follow-up dental visits Follow-up visits consisted of crown and
normal recall. appointments. No
follow-up visits for maintenance issues
or problems other than regularly
scheduled follow-up visits.
Follow-up visits consisted of permanent
restoration and/or crown and normal recall
appointments. Some participants
did not go to their recalls because they
were not in pain.
ENDO groups, endodontically treated groups.
Clinical Research
JOE Volume 37, Number 7, July 2011 Quality of Life of Endodontically and Implant Treated Patients 907
Page 5
with posterior implants seemed less aware of esthetic changes
compared with those who had implants placed in the anterior area.
Also, in one case, the participant got a full gold crown because it was
recommended by the restoring dentist, and he was not happy with
how much it stood out. A few others commented on the fact that there
is a dark area near the gum line that stands out when they look in the
mirror and in pictures. A few participants also noted a concavity or
recession of their gingiva around their implants.
All participants in the endodontic group either thought that the
endodontic treatment either had no effect on their appearance or
made it better. Some stated that considering the alternative of losing
the tooth, it made a considerable effect on their appearance, no matter
whether the tooth was in the anterior or posterior. Others thought that
because their root canal was in the posterior, it had no effect on
esthetics. One participant stated they were pleased the root canal could
be done through their previous crown and that they did not have to
remove it before their root canal was performed.
Functionality
Eating/Drinking.
The functional aspect of implant placement is one
of the most commented aspects of implant placement. In many cases,
participants were happy that they could return function to the area of
the mouth where the implant was placed. Many commented that their
implant functioned like a real tooth. A few participants said they still
chew on the opposite side out of habit or because they are trying to
protect the implant. A common complaint was that they get food stuck
between the implant and the teeth next to it. A few participants
mentioned not eating hard foods such as carrots or not biting directly
into an apple because they were told to by their doctor who placed the
implant, or they just wanted to protect it.
Many endodontic participants stated that they started using the
tooth to eat again or started chewing on that side of their mouth again.
Some stated the endodontic treatment had no effect on their eating and
drinking.
Psychological Discomfort. Many individuals in the implant
group mentioned trying to protect the implant or being more careful
with it because of its cost or because they are afraid they might break
it or lose it. Others mention that it feels different or looks different,
but it might just be psychological. Some individuals who had bone graft-
ing mentioned the fact that the bone was from a pig or cow. They did not
like the thought of having animal or foreign material in them.
With any treatment, there is a psychological aspect to consider. Ad-
dressing this, one endodontic participant stated, ‘It’s really important
for me to keep my teeth. It always has been. It’s kind of a combination
of things, the psychological aspect; these are body parts of mine I’ve had
my whole life. I’m kind of attached to them, and there’s the emotional
side too. I wouldn’t want to lose a finger or a toe if I could help it.’
Others commented that they feel more confident now that they saved
their tooth and smile more. Some stated they were glad to have the infec-
tion or abscess gone.
Physical Disability. As mentioned earlier, there were participants
in both groups who said they either protect their tooth or implant by
trying to eat in other areas of their mouth or by eating slower.
Cleaning/Maintenance. Most participants in the implant group
take better care of their teeth and get their teeth cleaned more often
since their implant because they do not want to lose any more teeth.
They also brush and floss around the implant more to keep food
from getting caught or because they want to take good care of it.
Some even mentioned using a toothpick or proxibrush to get between
their implant and the teeth next to it. Others mentioned using an electric
toothbrush now. A few mentioned that with their new crown, it is harder
to floss between their teeth and that floss gets stuck there. Similar to the
implant group, endodontic participants also have not changed their oral
hygiene habits or they have improved them. Some say they floss more
often, and a couple of people talked about the floss getting stuck
between their new crown and the teeth next to it.
Comparison to Other Teeth. Some participants mentioned that
their implant felt different than their other teeth. One example of this
was, ‘It doesn’t feel real for me. I mean, like, I know which one it is.
It operates the same way and it doesn’t bother me, but I don’t know,
I can tell it’s not my tooth when I touch it.’ A couple of people
mentioned that it used to feel different to them, but over time they
have gotten use to it and it feels more natural now. Those who were
missing a tooth for a while before the implant was placed thought
that the implant was kind of sticking out and pressing against their
tongue and felt wider than normal. A few others mentioned that their
implant feels very ‘strong’ and feels like a natural tooth.
Most participants in the endodontic group agree that the tooth
feels the same as their other teeth and does not feel any different. A
couple of people think it feels stronger. A few people said they notice
it sometimes; they do not have pain but rather sensation. Others said
they no longer feel hot or cold in the tooth, but they like that.
Permanency of Treatment. Several participants in the implant
group stated that they were afraid their crown may come off or that
the implant may fail. Others were surprised to hear that their treatment
may not be permanent and that problems could ensue in the future.
Some just thought once they got it, it was permanent and nothing could
happen. Similar to the implant group, the endodontic group seemed to
not really know much about the permanency of treatment or how long
the tooth would last in their mouth.
Follow-up Dental Visits. In the implant group, no follow-up visits
for maintenance issues or problems were mentioned other than regu-
larly scheduled follow-up visits and visits for crown placement. Simi-
larly, most participants in the endodontic group said the follow-up
visits consisted of getting the permanent restoration or crown and/or
normal recall appointments. Some went to their normal recall visits,
but some said they did not go to their scheduled recalls because they
were not in pain.
Discussion
Endodontic therapy and single implant-based supported pros-
thesis are viable treatment options for compromised teeth. Both
treatment modalities enjoy high clinical success rates and favorable
long-term outcomes supported by evidence-based quantitative research
(6, 17, 18). This study provides qualitative data showing a high rate of
patient satisfaction with both treatment options. It is important to realize
that implant therapy and endodontic therapy are two different treatment
modalities with their own unique indications and contraindications;
therefore, they should not be in competition with each other.
When analyzing the comments and concerns raised by the partic-
ipants, we should weight them based on how their severity and duration
will affect the quality of life of our patients. The most common themes
raised by the participants were transient and had a short-term effect on
their quality of life. For example, opening the mouth for a long period
was a common concern for both groups. Although important, this
concern will cause minimal or no effect on the patient’s quality of
life. Moreover, because this study was conducted on patients attending
the graduate student clinics, it may not be as much of a concern in the
private sector where practitioners have more experience and may be
more proficient during treatment than in a university-based setting.
The data presented in this study provide a very unique insight into
our patients’ feelings and perceptions and should be considered by the
Clinical Research
908 Gatten et al. JOE Volume 37, Number 7, July 2011
Page 6
providers when evaluating different treatment options. In addition to the
prognosis and outcomes, clinicians should consider patients’ perceptions
and preferences as well as the influence each therapy may have on their
quality of life, both short- and long-term. Overall, all the participants in this
study were pleased with the treatment received and expressed a clear
message to save their natural dentition whenever possible.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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  • Source
    • "However, an increasingly diverse range of patient cases has led to a situation in which it is impossible to ascertain such aspects of actual practice as prosthesis type and design, making it necessary to reaffirm the importance of treatment carried out from a prosthetic perspective [12]. Many surveys querying dentists or patients with regard to implant treatment have been reported in the literature, addressing such topics as the state of implant treatment in particular countries and regions [13,14], quality of life and patient satisfaction151617, peri-implantitis and mucositis [18], and implant education [19,20]. However, very few surveys have queried dental technicians, whose job it is to fabricate implant prostheses [21,22]. "
    [Show abstract] [Hide abstract] ABSTRACT: There are many implant cases in which dental technicians take initiative with regard to the design of implant prostheses, and to a certain extent, this area of care is one in which dentists do not necessarily play the leading role. Moreover, inadequate communication between dental technicians and dentists and insufficient instructions for technicians has been highlighted as issues in the past. The purpose of this questionnaire is to improve the quality of implant prostheses and thereby contribute to patient service by clarifying, among other aspects of treatment, problem areas and considerations in the fabrication of implant prostheses, conceptual-level knowledge, and awareness of prosthodontics on the part of the dentists in charge of treatment and methods for preventing prosthetic complications. Methods A cross-sectional survey was given to 120 certified dental technicians. To facilitate coverage of a broad range of topics, we classified the survey content into the following four categories and included detailed questions for (1) the conditions under which implant technicians work, (2) implant fixed prostheses, (3) implant overdentures, and (4) prosthetic complications. Results Out of 120 surveys sent, 74 technicians responded resulting in a response rate of 61.6%. Conclusions This survey served to clarify the current state of implant prosthodontics, issues, and considerations in the fabrication of implant prostheses, and the state of prosthetic complications and preventive initiatives, all from a laboratory perspective. The results of this survey suggested that, to fabricate prostheses with a high level of predictability, functional utility, and aesthetic satisfaction, it is necessary to reaffirm the importance for dentists to increase their prosthetic knowledge and work together with dental technicians to develop comprehensive treatment plans, implement an organized approach to prosthesis design, and accomplish occlusal reconstruction.
    Full-text · Article · Dec 2015
    • "However, patients' general satisfaction was higher after treatment by specialists (Hamasha & Hatiwsh 2013). As pre-treatment apprehension influences postoperative pain occurrence (Dugas et al. 2002, Gatten et al. 2011), a positive impact of an expert operator may emerge from shorter operating time and more efficacious communication when dealing with patient stress (Dugas et al. 2002, Hamasha & Hatiwsh 2013). Moreover, a significantly higher number of pecking motions needed by an inexpert operator to reach full WL may increase debris formation and risk of irritant extrusion (Tanalp & G€ ung€ or 2014). "
    [Show abstract] [Hide abstract] ABSTRACT: Aim: To compare the impact of rotary and reciprocating instrumentation on post-operative quality of life (POQoL) after single visit primary root canal treatment. Methodology: A randomized controlled clinical trial was designed and carried out in a University endodontic practice in northern Italy. Healthy subjects with asymptomatic irreversible pulpitis, symptomatic irreversible pulpitis or pulp necrosis with or without apical periodontitis (symptomatic or asymptomatic), scheduled for primary root canal treatment were enrolled. Single-visit root canal treatment was performed with ProTaper(™) S1-S2-F1-F2 (rotary group, N=23) and WaveOne(™) Primary (reciprocating group, N=24). Irrigation was performed with 5% NaOCl and 10% EDTA. Root canal filling was performed with the continuous wave technique and ZOE sealer. POQoL indicators were evaluated for 7 days post-treatment. The variation of each indicator over time was compared using ANOVA for repeated measures (P < 0.05). The impact of each variable on POQoL was analyzed with a multivariate logistic regression model (P < 0.05). Results: Pain curves demonstrated a more favorable time-trend in the rotary group (mean, P = 0.077; maximum, P = 0.015). Difficulty in eating (P = 0.017), in performing daily activities (P = 0.023), in sleeping (P = 0.021), in social relations (P = 0.077), were more evident in the reciprocating group. Patients' perception of the impact of treatment on POQoL was more favorable in the rotary group (P = 0.006). Multi-rooted tooth type and pre-existing peri-radicular inflammation were associated with a decrease in POQoL. Conclusion: Reciprocating instrumentation affected POQoL to a greater extent than rotary instrumentation. This article is protected by copyright. All rights reserved.
    No preview · Article · Oct 2015 · International Endodontic Journal
  • Source
    • "Therefore, preserving natural teeth should be the primary goal of oral care. Also patients express a clear message to save natural teeth whenever possible (Gatten et al. 2011). In a review by Iqbal & Kim (2008), it was concluded that a single implant serves as a good alternative for endodontic treatment when prognosis of the latter is considered poor (Iqbal & Kim 2008). "
    [Show abstract] [Hide abstract] ABSTRACT: Aim: To provide an update on the use of Patient-Reported Outcome Measures (PROMs) in the field of implant dentistry (1); to compare PROMs for prostheses supported by one or more implants to alternative treatment options or a healthy dentition (2). Materials and methods: The dental literature was searched on PubMed until December 31, 2014, using a general search algorithm. An overall quantitative analysis was performed, and a qualitative appraisal was made on the output of the last 6 years. Per type of edentulism and prosthetic treatment, the general search algorithm was refined in order to select controlled studies comparing PROMs for prostheses supported by one or more implants to alternative treatment options or a healthy dentition. Results: With nearly half of the output (300 of 635) published in the last 6 years, there is a growing interest in PROMs by the scientific community. When scrutinizing the 300 most recent publications, only 84 controlled studies could be identified among which 38 RCTs and 31 cohort studies. An "ad hoc" approach is commonly employed using non-standardized questions and different scoring methods, which may compromise validity and reliability. Overall, 39 eligible papers related to fully edentulous patients treated with an implant overdenture (IOD) and 9 to fully edentulous patients treated with a fixed implant prosthesis (FIP). There is plenty of evidence from well-controlled studies showing that fully edentulous patients in the mandible experience higher satisfaction with an IOD when compared to a conventional denture (CD). This may not hold true for fully edentulous patients in the maxilla. In general, fully edentulous patients seem to opt for a fixed or removable rehabilitation on implants for specific reasons. Data pertaining to partially edentulous patients were limited (FIP: n = 6; single implants: n = 16). In these patients, the timing of implant placement does not seem to affect patient satisfaction. Patients seem to prefer straightforward implant surgery over complex surgery that includes bone grafting. Conclusion: There is an urgent need for standardized reporting of PROMs in the field of implant dentistry. Fully edentulous patients in the mandible experience higher satisfaction with an IOD when compared to a CD. All other types of prostheses have been underexposed to research.
    Preview · Article · Sep 2015 · Clinical Oral Implants Research
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