Tooth loss and prosthetic replacements among persons with dependency and functional limitations

Abstract: The overall aim of this thesis was to obtain a decision basis for assessments and planning regarding prosthetic treatments for persons with dependency and functional limitations. For this purpose the epidemiology of tooth loss and prosthetic replacements was mapped out, and the patient perspective was reflected in studies performed in Norrbotten County, the northernmost part of Sweden. As a reference for study design, data from an epidemiologic survey of oral health among the general population in the same geographical region, EPINorr, was used. The study populations were sampled from the register of the increased financial support system in Norrbotten County and included a. Elderly in nursing homes, b. Persons with certain functional impairments (covered by the Act Concerning Support and Service, LSS), c. Home-care patients with dependency and functional limitations, and d. Independent persons with long-lasting functional limitations with extensive need for dental care due to illness that causes functional impairments. The results from the study populations were compared with results from matched controls sampled from the register of dental records in the Public Dental Service in Norrbotten County in Study I and with data from the EPI-Norr study in Study II. The first three studies were observational cross-sectional studies with data collection from dental records in Study I, by clinical examinations in Study II and by questionnaires in Study III. In Study I, the prevalence of tooth loss and performed prosthetic treatments was compared with results from matched controls representing the general population. In Study II, oral status and prosthetic replacements were described, and prosthetic treatment needs were defined and compared with results from a general population. The results showed that the study population had fewer teeth, a higher proportion of complete tooth loss, more dentures and fewer tooth- and implant-supported prostheses compared with the control groups from the general population. In Study II, 42% of the dentures in the upper jaw and 51% in the lower jaw were in poor condition. The study population had fewer occlusal posterior contacts compared with the control population in all ages. Elderly in nursing homes had the lowest number of teeth and highest proportion of complete tooth loss, but all categories had fewer teeth compared with the control populations of the same ages. The study subjects in Study II who were able to answer questions in a questionnaire were invited to participate in Study III, in which possible associations between tooth loss, prosthetic replacements, oral health-related quality of life (OHRQoL) and health-related quality of life (HRQoL) were examined. The aim was also to study if the chosen quality of life instruments GOHAI, OHIP-14 and RAND-36 were appropriate to use in the actual population. The results showed weak associations between clinical variables and the results of the questionnaires, which indicates that it may not be appropriate to use common OHRQoL instruments in populations with care-dependency. Elderly in nursing homes had the poorest oral status among the different categories, yet they reported the best QoL. The majority in this category thought that they could manage with the current situation after they lost teeth but half of them reported that they could not eat all kinds of foods. Study IV was a qualitative interview study aimed at exploring the experience of receiving and living with dental implants among persons with functional limitations. 17 patients with several types of functional impairment who had undergone treatment with dental implants were interviewed. Analysis of the open-ended questions began at the first interview and proceeded concurrently until no further relevant information could be obtained. In the results, ‘The implant treatment is a process of normalization’ was identified as the core category. It was related to four other categories: ‘The functionally impaired are also entitled to dental care’, ‘Edentulousness is a burden for functionally impaired individuals’, ‘There is interaction between implant treatment and other aspects of life’ and ‘It is important to understand the implications of implant treatment’. The conclusion of the thesis is that despite the favourable conditions in Sweden for oral healthcare of persons with dependency and functional limitations, there are great differences in tooth loss and how tooth loss is treated compared with a general population. There are more dentures and fewer tooth and implant-supported prostheses among these persons even if interviews show that some of them can benefit from treatment with dental implants. However, this is difficult to confirm through validated oral health-related quality of life instruments. This vulnerable population does not often actively demand dental and oral care, and thus their needs have to be identified in other ways and by other professionals than dental healthcare services.