18 July 2024: Clinical Research
Impact of Denture Use on Oral Health-Related Quality of Life in Yemeni Patients: A Cross-Sectional Analysis
Nadhra N. Alalwani







DOI: 10.12659/MSM.944682
Med Sci Monit 2024; 30:e944682
Abstract
BACKGROUND: We used the 14-item Oral Health Impact Profile-14 (OHIP-14) questionnaire to evaluate the association between sociodemographic variables and oral health-related quality of life in 241 wearers of removable partial or complete dentures attending a single center in Yemen.
MATERIAL AND METHODS: A total of 241 partial dentures (PD) and complete dentures (CD) wearers were enrolled from the Department of Prosthodontics at the Faculty of Dentistry, Sana’a University, and the University of Science and Technology. Data were collected before the commencement of denture wearing and after 3-6 months of denture use. The questionnaire consisted of sociodemographic information and denture type, and another for the OHIP to assess oral health-related quality of life (OHRQoL), oral health impact profile scale comprises 7 subscales, each evaluating different aspects of oral health and functionality. Descriptive statistics were calculated for participants. Independent t tests were performed to compare different patient groups, focusing on PD and CD wearers. Paired-sample t tests were used to examine changes within patient groups before and after removable denture use.
RESULTS: Among all participants, 67.6% were male, wearers of CDs were 74.6% male, PDs were 58.3%, and was consistent for CD (71.0%) and PD (72.8%) wearers. The wearing prostheses significantly impacted the OHRQoL of patients using both PDs and CDs (P<0.01). Among CD wearers, 4 of these subscales (3-6) were statistically significant, but the handicaps subscale showed evident reductions in physical pain after treatment among PD wearers.
CONCLUSIONS: Wearing dentures positively affects the OHRQoL of patients, influencing various aspects of their health, including functional, physical, psychological, and social well-being.
Keywords: Dentures, Oral Health, Quality of Life, Humans, Male, Female, Cross-Sectional Studies, Middle Aged, Yemen, Surveys and Questionnaires, Aged, Denture, Partial, Removable, Denture, Complete, adult
Introduction
The leading causes of poor dental health include caries, periodontal diseases, and edentulism, with edentulism often arising as a final consequence of caries and periodontal diseases [1]. Edentulism is characterized by the absence of natural teeth and can be either complete or partial [2]. These states of partial and complete edentulism are enduring and irreversible conditions, often stemming from dental infections or trauma [3]. They have even been proposed to be categorized as a form of disability and may potentially be associated with reduced longevity [4].
Four types of partial edentulism are demarcated, Class I to IV, through Class I and IV seeing as uncomplicated and difficult clinical condition. It is used by dental professionals in analysis and treatment of partially edentulous patients. Among its benefits are improved diagnostic consistency, enhanced intra-operator reliability, improved professional communication, insurance reimbursement appropriate with complexity of care, amended screening for dental college admission clinics, simplified aid in the decision to refer a patient, and uniform criteria for outcomes assessment and research [5,6]. A removable dental prosthesis can be suitable pretreatment among patients with moderate tooth loss [7].
However, even when a patient maintains good overall physical health, missing teeth can significantly impact various aspects of life, including functions, speech, appearance, and self-esteem. This can lead to physical, functional, and psychological challenges that ultimately diminish a patient’s quality of life (QoL). Therefore, evaluating patients with missing teeth requires considering more than just their physical characteristics; it should also involve an assessment of the physiological and emotional factors driving their treatment request [8].
According to the World Health Organization (WHO), health is defined as “complete physical, mental, and social well-being,” extending beyond the mere absence of disease. In line with this definition, the WHO characterizes quality of life (QoL) as “an individual’s perception of their position in life within the cultural and value systems of their society, and concerning their objectives, expectations, norms, and concerns” [9,10]. Oral health-related quality of life (OHRQoL) is specifically defined as “the absence of adverse effects of oral conditions on social interactions and a positive sense of self-confidence related to one’s oral and facial appearance” [11]. The concept of OHRQoL began to gain recognition in the 1980s and is distinct from the general health-related QoL concept, which emerged in the late 1960s. A potential reason for the delay in developing OHRQoL could be the limited awareness of the impact of oral conditions on overall QoL [12]. Oral Health Impact Profile-14 (OHIP-14) includes trouble pronouncing words, impaired sense of taste, difficulty with work or tasks, discomfort when eating, pain or aching, self-consciousness, difficulty relaxing, feelings of stress or anxiety, lack of satisfaction with meals and diet, irritation with other people, dissatisfaction with life, interruption to meals, embarrassment, and a total inability to function [13,14].
Theoretical models define OHRQoL as a multidimensional concept consisting of 7 subscales: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap [15–17]. Numerous studies have indicated that dental diseases can negatively affect a person’s ability to enjoy life, engage socially, and perform well at work. By contrast, different stages of prosthetic treatment can help patients maintain a positive outlook [18–20].
A recent study by Berniyanti et al found that partially edentulous patients, both with and without dentures, showed significant correlations between domains of physical and psychological health and those of social and environmental aspects [21]. Various indicators of patient dental satisfaction, such as chewing, taste perception, pain, speech ability, and aesthetic perception, play a pivotal role in influencing overall QoL [22–27]. Other studies among other populations assessed the quality of life and concluded a positive result between the tested pamperers [28,29].
When evaluating the outcomes of prosthetic treatment, it is essential to consider clinical indicators and patient satisfaction [30]. Clinical indicators alone are insufficient to capture the functional and psychosocial aspects of treatment, as it is crucial to adequately address patient needs and preferences [31,32]. The acceptance and success of dental prostheses are primarily determined by a combination of biological, mechanical, aesthetic, and psychological factors. Notably, factors like mastication and speech are pivotal, whereas a clear association of patient satisfaction with age, general health, and hygiene has yet to be established [33].
In Yemen, as in other countries, few studies related to the OHRQoL concept have been conducted. Therefore, additional research that acknowledges the importance of OHRQoL is essential. The present study aimed to evaluate the association between sociodemographic variables and oral health-related quality of life in 241 wearers of removable partial or complete dentures attending a single center in Yemen, using the 14-item Oral Health Impact Profile-14 (OHIP-14) questionnaire.
Material and Methods
STUDY DESIGN AND ETHICAL APPROVAL:
This clinical study received ethics approval from the ethics review committee of the Faculty of Medicine and Health Sciences at Sana’a University, Yemen (#89/January/30/2021). The study procedures were explained to the patients, and informed consent was obtained using forms provided to the participants along with the OHIP questionnaire, where the results were transcribed. This study focused on patients requiring complete and partial dentures at the Department of Prosthodontics, Faculty of Dentistry, Sana’a University, and the University of Science and Technology. The patients were treated by undergraduate dental students under professional supervision.
SAMPLE SIZE CALCULATION AND PARTICIPANTS:
We estimated the effect size for our primary outcomes through an extensive literature review and expert consultations, followed by a power analysis using G*Power and the Open Epi software. This analysis indicated that a sample of 230 patients achieved an 84% power level for the paired samples
INCLUSION AND EXCLUSION CRITERIA:
The inclusion criteria were: partial or complete edentulism requiring prosthetic treatment; aged 18 years or older; and without ridge defects, without mental illnesses, and with means for contact (telephone/mobile numbers). Patients had finished all treatment phases before starting the prosthetic phase (the phase of construction of CDs and PDs). The exclusion criteria were: any patient attending the clinics for other purposes; patients younger than 18 years; and patients with severely resorbed ridges, with any mental problems, and without means for contact (telephone/mobile numbers).
SELECTION OF PARTICIPANTS:
There were 640 participants who fully satisfied the inclusion criteria and who had either CD or PD and were treated during study period. All the selected participants were informed about the study and we only included participants who agree to be involved in the current study. Only 241 agreed to continue to the end of the study, the remaining patients were withdrawn due to lack of transportation, moving to other cities, or not return during the follow-up appointments.
KENNEDY CLASSIFICATION OF PARTIAL DENTURES PARTICIPANTS:
The PD participants were characterized according to the Kennedy classification, in which those patients were categorized in relation to the patterns of partial edentulism.
QUESTIONNAIRE SECTIONS:
The researcher translated the questionnaire parts for each patient and documented their responses on a designated sheet, which was later transferred to Microsoft Excel. The questionnaire was consisted of 2 parts. The first section included sociodemographic information and denture types, while the second section encompassed the oral health impact profile (OHIP). OHIP-49 originally consisted of 49 items grouped into 7 subscales [14,34] as elaborated below. Several studies have validated the original OHIP-49 for use in academic research [13,35,36]. The quality of the assessments generated by the condensed and translated versions of the original tool closely parallels that of OHIP-49. Many authors, including Al Jundi et al, have confirmed the tool’s reliability and validity [37].
In accordance with the approach advocated by Slade and Spencer [13], several researchers have developed condensed iterations of the original instrument. These condensed versions retained the same subscales but reduced the number of items, resulting in assessment measures with increased time efficiency and user-friendliness [13,35–39].
The OHIP-14, which was utilized in this study, represents one of OHIP’s most condensed and validated versions. It was selected due to its minimal limitations that might introduce bias into the results and, due to its simplicity and brevity, it is suitable for the predominantly uneducated sample of this study while still maintaining the required validity for conducting assessments. The testing for removable partial denture patients’ satisfaction were recommended and designed earlier [40,41].
We calculated the reliability of internal consistency using Cronbach’s α coefficient, developed by Cronbach in 1971. The value of the reliability coefficient of the data collection tool (questionnaire) was 82%, indicating that the items (scales and subscales) used in the questionnaire are internally consistent.
The 14 questions include trouble pronouncing words, impaired sense of taste, pain or aching, discomfort when eating, self-consciousness, feelings of stress or anxiety, lack of satisfaction with meals and diet, interruption to meals, difficulty relaxing, embarrassment, irritation with other people, and difficulty with work or tasks. The validated condensed version of the OHIP tool consists of 7 scales and 14 subscale questions. It utilizes Likert scale responses to gauge the OHRQoL of CD and PD wearers. The original OHIP scale consists of 7 scales, which collectively assess various facets of oral health and functionality, providing a comprehensive evaluation of the patients’ OHRQoL [13]. The scale’s 7 subscales are:
We translated the questionnaire queries for each patient and documented their responses on a designated sheet, which was later transferred to Microsoft Excel.
SCORING METHOD AND RESULT EVALUATION:
The participants’ responses to the questionnaire items were evaluated using a Likert scale ranging from 0 to 4, with 0 indicating “never,” and 1, 2, 3, and 4 representing “seldom,” “sometimes,” “often,” and “always,” respectively. Responses marked 0, 1, and 2 indicate a positive effect of oral health on an individual’s life, whereas responses 3 and 4 suggest a negative effect [10,27,39]. The simple count method was applied to score the questionnaire responses. The total score was calculated by summing the number of effects reported frequently. The data were collected before the start of denture wearing and after 3–6 months of denture use.
STATISTICAL ANALYSIS:
The collected data were analyzed using SPSS software, version 23.0 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics were computed, including the frequency of responses, response means, percentages, and standard deviations for each subscale item. Independent
Results
DEMOGRAPHIC DATA:
Table 1 displays the demographic information describing the pertinent characteristics and health-related assessments of the sample. The data revealed that most study participants (67.6%) were male. Moreover, the subsample of patients with CDs (74.6%) was much larger than those with PDs (58.3%). Given that a significant portion of elderly individuals wear dentures (80.5%), which was slightly higher proportion of retirees (71.8%), this trend was consistent for CD (71%) and PD (72.8%) wearers.
The sample population was queried regarding their systemic conditions, such as diabetes and high blood pressure, showing that 29.5% of the participants had a systemic illness. Among these participants, 12.6% had diabetes, with 22.5% being CD wearers, and 9.4% had hypertension, with 13.6% being PD wearers.
The sample consisted of nearly equal proportions of educated (51.5%) and uneducated (48.5%) patients. An analysis of denture types revealed that out of the 241 patients included in the study, 138 (57.3%) had CDs, whereas 103 (42.7%) had PDs, as depicted in Figure 1. The distribution and numbers of PD patients in relation to Kennedy classification are presented in Figure 2, in which the highest number and percentages were recorded in class II in both maxillary 20 (50.0%) and mandibular arch 30 (47.6%).
NORMALITY TEST:
The Shapiro-Wilk test showed that data for CP and PD and CD: PD ratio were normally distributed (
EVALUATION OF OHRQOL BEFORE AND AFTER DENTURE WEARING:
Table 2 presented the self-reported OHRQoL scores of patients measured using OHIP before and after denture wearing (CDs and PDs). A statistically significant difference was found between the mean pre-OHIP scores and post-OHIP scores in favor of the post-test scores. The post-test scores were marginally lower by 3.9 than the pretest scores. Notably, all subscales, except the first 2 subscales of functional limitations and physical pain (P>0.05), exhibited statistically significant differences (p<0.01) in the standalone assessments.
EVALUATION OF OHRQOL BEFORE AND AFTER CD WEARING:
Table 3 presents the mean pre-test scores (16.570) and post-test scores (14.500) of the CD wearers, revealing minor differences between the 2 assessments. The overall scores, reflecting the difference between pre- and post-CD wearing, had a marginal difference of 2.07. Notably, 4 of the 7 subscales (3–6) were statistically significant.
EVALUATION OF OHRQOL BEFORE AND AFTER PD WEARING:
Table 4 show that the difference between the overall pre- test scores (20.21) and post-test scores (13.83) of PD wearers exhibited a notable difference of 6.38. The overall scores reported by PD wearers showed the highest difference. Significant findings were identified for 6 out of the 7 subscales (subscales 2–7).
RELATIONSHIP BETWEEN THE SOCIODEMOGRAPHIC CHARACTERISTICS AND OHRQOL OF DENTURE WEARERS:
An independent sample t test was applied, as presented in Table 5, to delve deeply into the relationship between the sociodemographic characteristics and OHRQoL of CD and PD wearers. In terms of participant gender, males accounted for a more significant portion of the overall denture-wearing population than females, with 163 (67.6%) of the respondents being male. However, for PD wearers, no statistically significant factors were identified concerning OHRQoL. Age, education, occupation, and hypertension did not exhibit statistically significant relationships with total OHIP scores (P>0.05). For CD wearers, statistically significant relationships (P<0.05) were found between total OHIP and the following variables: (1) gender of the patient, (2) presence of systemic illness, and (3) diabetes.
Discussion
Using the OHRQoL measurement tool, this research aimed to evaluate and compare the differences in OHRQoL before and after wearing removable CDs and/or PDs and to investigate the relationship between the sociodemographic characteristics and OHRQoL of CD and PD wearers among selected Yemeni subjects. The OHIP-14 was used in this study, since it is one of OHIP’s most condensed and validated versions, and because it has minimal limitations that might introduce bias into the results and it is suitable for the predominantly uneducated sample. Also, these data are essential for examining shared traits and differences within the sample, exploring potential connections between demographic factors and the observed effect of denture wearing on OHRQoL, and documenting statistically significant observations made during data analysis.
Studies utilizing the OHIP scale have shown that patients with poor oral health have high overall OHIP scores due to their many missing teeth, retained root fragments, decay, and (untreated) deep periodontal pockets and recessions [9,33,39]. Therefore, the high scores obtained in this work demonstrated the sample’s low overall OHRQoL. Also, removable dentures have a positive effect on the OHRQoL of the participants. This finding paralleled the results documented in populations in other low-income countries [10,21,29,42–45], but some of the findings might not match the findings of studies conducted in other countries [46], likely due to economic status and the free prosthetic services provided by government clinics.
The standalone findings for each subscale, except for the functional limitations and physical pain, had statistically significant differences between pre- and post-recordings with CD wearers. This was related to psychological and physical factors, although in the present study, psychological implications may be greater than physical implications. Similarly, Awad et al reported that psychological factors had greater effects than physical factors [47]. This result is somewhat aligned with the observations in the literature, wherein the physical implications of prosthodontic applications were mostly observed in terms of patients’ functional status, whereas psychological implications encompassed factors, such as aesthetics, social factors, and general discomfort, which appeared to be highly prevalent in prosthesis wearers [4,48]. Those factors may be attributed to the current humanitarian situation in Yemen, which may have a notable effect on the deterioration of the psychological health of patients. Therefore, patients need any form of QoL improvement to improve psychological status; such an improvement may be provided by RD wearing [49]. In the comparison of these findings with prior results, some discrepancies emerged regarding physical pain and functional limitations related to prosthesis wearing because authors often emphasize physical aspects over psychological ones [50]. Another study proved that in general, CD and PD wearers still had impaired OHRQoL [42].
Out of the 7 subscales, 4 (subscales 3–6) were statistically significant and 3 (1, 2, and 7) were nonsignificant, whereas the means of pre- and post-test OHIP scores for all the subscales were positive. This outcome may be attributed to the following: CD wearers may be more aware of their handicap and may be better at functioning with dentures than PD wearers because they had transitioned to their current situation through partial edentulism [51]. Moreover, they may realize that any RD has functional limitations, and they may attempt to adapt to pain and consider it is as an outcome of edentulism [30,52].
The mean pre- and post-test scores of PD wearers decreased considerably between assessments, except for the subscale of functional limitation, which had the highest difference reported for the overall scores in this study. This result may be due to the remarkable differences in chewing between patients with partial and complete edentulism, which could possibly lead to irregularities in chewing movements [52]. Patients with partial edentulism who maintained periodontal mechanoreceptors present better jaw control and smoother chewing patterns than those with complete edentulism [53]. This interpretation might be proven by the mean OHIP scores, which increased from negative to positive in the post-test. This finding aligned with the results of a study that showed a statistically significant correlation between the OHRQoL domains of physical health, psychological health, society, and environment and the domain of OIDP in patients with partial edentulism and implants or conventional dentures [21].
The second subscale of physical pain presented a mean of 3.02, which indicates a negative effect, in the pre-OHIP assessment, and 2.33, which indicates a positive effect, in the post-OHIP assessment. This result revealed improvement in the physical pain experienced by the subjects; such pain may be attributed to the presence of teeth that might be affected by caries or periodontal disease [1]. Furthermore, tooth movement, such as drifting and overeruption that occurred due to tooth loss, resulting in malocclusion, may cause pain during mastication because of the change in the long axes of the teeth and subsequent alterations in the occlusion of the patient that may lead to pain in teeth and temporomandibular joints [54]. The negative pre-assessment scores of PD wearers may represent the recently documented significant negative effect of edentulism on physical and psychological health, as well as economic aspects [21,45].
An in-depth investigation of the diagnostic procedures used in the prosthodontic clinics of colleges revealed that the dental status of a patient is comprehensively assessed before denture construction, such that any tooth with a defect is treated or extracted. This situation may account for the improvement in physical pain and functional factors after PD wearing.
This study did not confirm the negative effects reported by other studies [13,20,39] on the social well-being of patients with poor oral health. Instead, this work found that CD and PD wearing had significant effects on the sixth subscale (social handicap) of the OHIP scale that were within positive scores, indicating positive improvement. In PD and CD wearers, the mean differences for the handicap subscale were within positive scores, illustrating that the research population was not completely handicapped. This may be attributed to the degree of difference between pre- and post-OHIP assessments that resulted in the significant results of PD wearers and nonsignificant results of CD wearers.
Demographic data revealed differences in gender and generally better oral health among females than males. Darviri et al and Szwarcwald et al documented that females have a higher awareness of oral health practice than their male counterparts [55,56]. One possible explanation for this phenomenon is that females tend to be more concerned about their overall health and appearance than males. Such a situation may influence their ratings of OHRQoL measures. This result also aligned with findings that proved females are more likely to experience disability in various domains than males [44]. Moreover, the problems faced by females may be exacerbated with increasing age, likely in relation to increased irritability, loss of manual dexterity, and diminished adaptability with aging.
Some discrepancies were found between the findings for young and old patients as indicated in the demographic characteristics. Specifically, participants more than 50 years of age (80.5%) constituted most of the sample. This situation may indicate that older people were more affected by partial or complete edentulism either due to degenerative functional and/or neurocognitive disorders. Moreover, limited manual dexterity becomes increasingly prevalent as life expectancy improves and may affect oral health care and subsequent tooth loss [44,57].
Non-educated patients might be over-represented in this study because participants with low economic status received free treatment from colleges, and 71.8% of the participants were retired. The relative cost of oral procedures, especially procedures involving the application of prostheses, must be accounted for while considering the findings. The WHO 2020 stated that in most developing countries, such as Yemen, citizens find affording adequate oral treatments difficult given that many of them are classified as low-income citizens with incomes below or barely above the poverty line [58].
In terms of the relationship between sociodemographic characteristics and OHRQoL, in CD wearers, total OHIP had a statistically significant relationship with: (1) patient gender, (2) presence of systemic illness, and (3) diabetes, while it was not for PD wearers. The gender of the patient was significant due to the difference between the percentages of male and female participants. The higher mean scores of females (18.9) than those of males (13.0) indicated that OHRQoL showed more positive improvement in males than in females, likely because of the greater concern and worry felt by females about their health and appearance, which may have affected OHRQoL ratings [55].
Systemic illness was significant, likely because of the difference in percentage between the participants with and without systemic illnesses, with the score of the former group being worse than that of the latter. Finally, diabetes was found to be a significant factor, with patients with diabetes showing worse scores than those without. This result demonstrated that diabetes had a negative effect on OHRQoL. Studies concluded that this systemic illness has some effects on soft tissue development, which can influence the vascular supply and soft tissue quality and can lead to some variance in the OHRQoL of patients [59,60].
Major links exist among diabetes, oral health status, and denture use. Some of the observed effects on the oral health of CD wearers were observed in the palatine mucosa, which presented reduced local vascular circulation resulting from prosthodontic compression, in combination with poor oral health in patients [61,62].
This study explored whether any link can be identified between the use of CDs and PDs and oral health (as measured through OHRQoL) of a selected sample group of Yemeni denture wearers. The findings of this study indicated the potential for the effect of denture wearing on patients’ oral health, which, in turn, had been identified to influence the functional, physical, psychological, and social aspects of patients’ health. High levels of oral health problems can be anticipated among patients with poor general health and vice versa [63].
A core limitation of this study is related to the application and construction of dentures by dental students. This situation may influence the quality and fitting of the dentures. Therefore, the study’s findings may be different if the patients included in this research had their dentures applied by experienced dentists. Moreover, the findings of this study included self-report by patients, presenting a potential limitation related to the variability in the judgment of different people in ranking the items of the questionnaire by using the provided scale, as different patients are likely to have different perceptions of what constitutes good oral health. Another limitation is that the classification of patients with CD in one jaw and PD in the other jaw were not included during follow-up.
Conclusions
This study provides valuable insights into the positive impact of denture wearing on various dimensions of patients’ oral health-related quality of life (OHRQoL), including functional, physical, psychological, and social aspects. Notably, in the case of CD wearers, 4 significant subscales (3–6) demonstrated improvements, while PD wearers exhibited an additional subscale showing significant enhancement, particularly in relation to reduced physical pain following treatment.
Tables
Table 1. Demographic profile of the study sample in relation to the frequency of denture type (N=241).




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