Journal of Medicine and Medical Science Vol. 2(4) pp.794-804, April 2011
Available online @http://www.interesjournals.org/JMMS
Copyright © 2011 International Research Journals
Full Length Research Paper
Model development of mandibular two-implant retained
overdentures plus nutritional empowerment in elderly with
dentures (need) (Intermediate outcome)
Nawakamon Suriyan1* DDS, PGDip OMFS, FICOI, Ph.D PH (candidate), Sathirakorn
Pongpanich2 BEcon, MA, Ph.D, Surasak Taneepanichskul3 MD., MSc, FRCOGT , Settakorn
Pongpanich4, MD, DDS, FDSRCS (Edin).
1
Dental Implantologist, Prachatipat Hospital, Pathumthani, Thailand
Associate Dean and Director of Ph.D Study, College of Public Health Sciences, Chulalongkorn University, Bangkok,
Thailand
3
Dean, College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand
4
Assistance Professor, Prince of Songkhanakarin University, Thailand
2
Accepted 28 April, 2011
It is unclear whether the replacement of conventional dentures with mandibular two implant-retained overdentures
alters the diet selection and thus improves nutritional status and quality of life of elderly edentulous persons. In this
randomized clinical trial, the objective was to explore the effectiveness of IODNEED programme. Population was Thai
male and female, aged over 65years and edentulous for at least 1 year, n=33 in each group, living in Pathumthani
Province, Thailand. Intervention was Mandibular two implant-retained Overdentures (IOD) plus NEED (Nutritional
Empowerment in Edentulous people with Dentures). Comparison was among IODNEED, IOD only; Conventional
dentures (CD) plus NEED and CD only. Outcome was post-treatment differences in satisfaction, oral heath related
quality of life and nutritional status and anthropometric and blood parameters among the groups and measured
pretest, post 1 month, post 3 months and post 6 months. The research results found that all general characteristics
and pretest mean scores of most of the measured variables were not statistically significant difference among the
four groups (p-value >.05). Pretest mean scores of nearly all of variables measured among the four groups were not
significant different (p-value >.05). At post 6 months assessment, in IODNEED group, the best improvement was seen
in most of the variables than other three groups such as oral health related quality of life, masticatory function,
satisfaction, nutritional status, body mass index, daily diet intake, and 6 out of 7 items of blood nutrient parameters
were significantly higher than pretest (p-value <.001). Comparison between IODNEED and IOD, mean scores of serum
albumin, serum Iron, and red blood cells were significantly increased ((p-value <.001) in IODNEED. Between IODNEED
and CDNEED, nearly all of the variables such as oral heath related quality of life; mastication function, nutritional
status, and 4 out of 7 blood parameters were significantly increased in IODNEED (p-value < .02). From the results of
correlation and regression analysis of cost-effectiveness, IODNEED was better than IOD and CDNEED was better
than CD in term of oral health related quality of life and satisfaction (p-value < .001). Regarding masticatory function,
IOD was 6 times more effective than CD, in our studied population (p-value < .001). we can concluded that
“IODNEED” program had more effective in improvement of oral health related quality of life, mastication function,
satisfaction for mandibular, nutritional status, BMI, body fat percentage (skin fold thickness), and blood parameters.
Moreover, it can also be concluded that “NEED” had not only improvement in mean scores of studied parameters but
also effective by cost. Regular participatory nutritional empowerment and isometric exercise should be provided in
conjunction with mandibular two implant-retained overdentures in elderly edentulous Thai citizens.
Key words: mandibular two implant-retained overdentures, dental implants, edentulous, elderly, nutrition, dental prosthesis,
cost-effectiveness, Funyim
INTRODUCTION
Oral health is a standard of the oral and related tissues
which enables an individual to eat, speak and socialize
*Corresponding author: nawakamons@hotmail.com
without active disease, discomfort or embarrassment and
which contributes to general well-being (WHO, 1983). In
Thailand, the senior edentulous citizens waiting for dental
implants are 107, 366 persons, whereas, 2155 are
residing in Bangkok and 1038 in Pathumthani province.
Suriyan et al. 795
(King project MOPH Thailand, 2008).
Conventional dentures “CD” could not chew many
types of foods, particularly raw vegetables and other hard
and tough foods (Hartsook, 1974; Wayler and Chauncey,
1983; Chauncey et al., 1984). On the other hand,
mandibular two implant-retained overdentures “IOD” not
only can chew most of the foods (Feine et al., 1994;
Geertman et al., 1999) but also provides significantly
greater satisfaction, masticatory function, and oral healthrelated quality of life (OHRQoL) than CD (Awad et al.,
2000).
A few studies had reported deficiencies of isolated
nutrients in denture wearers, but there was no consistent
pattern. (Papas et al., 1998; Joshipura et al., 1996;
Greksa et al., 1995) Moreover, some studies generally
had shown that prosthetic rehabilitation in the absence of
dietary counseling does not lead to dietary improvement
(Moynihan and Bradbury , 2001; Moynihan et al., 2006;
Hildebrandt et al., 1997; Sahyoun et al., 2003; Sheiham
et al., 2001).
In this study, we explored the effectiveness of IOD plus
NEED programme by making comprehensive comparison
of the efficacies among three intervention groups and
control group in Thai elderly edentulous people in
Prachatipat hospital, Pathumthani province, in the aspect
of satistisfaction, OHRQoL, nutritional improvement and
cost-effectiveness. Thus we empowered one of the factor
related to food choice i.e knowledge, attitude and practice
concerning about healthy diet by NEED (Nutritional
Empowerment in Edentulous people with Dentures)
programme using participatory learning approach. Our
research question was “Can the combine effect of two
interventions (IODNEED) have better improvement in
patient satisfaction and nutritional status than the other
compared groups; IOD only, CDNEED, and CD only”. We
tested the null-hypothesis that there are no difference in
satisfaction, oral heath related quality of life and
nutritional status and anthropometric and blood
parameters among the groups and measured at pretest,
post 1 month, post 3 months and post 6 months.
MATERIAL AND METHODS
This study was a Randomized clinical trial. This study
was conducted in Prachatipat hospital, Pathumthani
province, Thailand. The study population for this study
were Thai edentulous people over 65 –year old age
attending (King project) “Project Dental Implant Honor”
during the study period from September 2010 to March
2011. The subjects were recruited from the waiting list of
elderly edentulous persons residing in Pathumthani
Province. The subjects were invited to participate in this
study by telephone conversation. All the patients who
agreed the study protocol were screened according to
inclusion criteria and exclusion criteria. Informed written
consent was obtained from all participants.
The estimated sample size was calculated by
comparisons of two means formula, according to
standard statistical criteria (α =0.05, power of the test =
90%). Difference between means and standard deviation
of two groups was used from previous study in 2003,
primary outcome patients’ satisfaction VAS, visual
analogue scale (Morais J.A et al., 2003). The sample size
calculated was 27 per each group and we added another
20 percent for estimated attrition. Participants were
randomly allocated to each of the four studied groups.
Subjects received either mandibular two implant-retained
overdentures (n=66) by “Funyim” Titanium grade IV, ISO
13485, provided from King, manufactured in ADTEC
(Advanced Dental Technology Center), Thailand or
conventional completes dentures (n=66) by new maxillary
and mandibular conventional dentures.
For the primary outcome of the study, general
satisfaction was measured by visual analogue scales (0
to 100) for maxilla and mandibular. The secondary
outcomes were quality of mastication function, oral health
related quality of health by OHIP oral health impact
profile, mini nutritional assessment, and anthropometric
measurement. These were gathered at pretest, post 1
month, post 3 months and post 6 months treatment.
Blood parameters such as serum albumin, plasma B12,
serum and erythrocyte folate, serum Iron, red blood cells,
haemoglobin, and total lymphocyte counts were tested at
pretest and post 6 months assessment. Data were
gathered by a dietitian and a trained public health nurse,
who were blind to research protocol.
Weight and height was measured by stadiometer
(DETECTO, donated by UNICEF), we measured to the
nearest 100gm, with light clothing and without shoes.
Waist and hip circumferences were measured with nonelastic tape. From height and weight, the Body Mass
Index was calculated. A Lange caliper was used for skin
fold thickness (SFT) measurements by two persons (a
trained dietitian and public health nurse), and from their
measurement in each person, within 1 mm were
averaged. The skin fold thickness was measures at
dominant side of body at biceps, triceps, subscapular,
abdominal and iliac crest area. Body fat percentage
(BFAT %, SFT) and Lean Body Mass were calculated by
Durnin & Womersley calculation (Durnin and Womersley,
1974). Past seven days daily dietary intake was also
collected at pretest, post 1 month, post 3 months, and
post 6 months.
Instruments for data collection: the questionnaires used
for data collection were as follows;
(1) For oral health related quality of health by OHIP 20
Thai version already adopted (John et al., 2006),
translated and used in King Project “Project Dental
Implant Honor”.
(2) Quality of mastication function (QMF) adopted from
original English language was translate to Thai by
researcher
(3) Mini Nutritional Assessment (MNA) (Guigoz Y et al.,
1996) was adopted and translated to Thai by researcher
796 J. Med. Med. Sci.
NEED
Workshop I
Objective
To give information of
nutrients and nutrients
portion
Content
Introduction of NEED
Nutrient portion
Nutrient sheets
Thai Food pyramid
Isometric exercise
Workshop II
To specify and select
daily food counting and
serving
Food counting
Shopping game
Food serving
Calculating food
game
Isometric exercise
Workshop III
To compare and apply
correct
daily
healthy
foods intake
serving
Twenty eight days food plan
Food choice
Dental
care
in
dental
prosthesis
Diet consultation for systemic
diseases
Isometric exercise
(4) VAS (McDowell I et al., 1996), visual analogue
satisfaction score maxilla and mandibular (VASMX,
VASMD) was adopted and translated by researcher.
Regarding the IOD surgery and NEED programme were
mentioned in Box 1.
The Ethical Review Committee for research involving
human research subjects, Health Science group,
Chulalongkorn University, Thailand, had approved and
the study title number is 037.2/53.
Material & Methods
Power point presentation
Nutrients paper sheets
Flipcharts
Small group discussion
Post
assessment
questionnaires
Power point presentation
Shopping games
Food model
Papers, Markers, Pen
Small group discussion
Post
assessment
questionnaires
Power point presentation
Photos, food models
Food choice, mixer game
Papers, Markers, Pen
Small group discussion
Post
assessment
questionnaires
All data were entered into the Epidata version 3.1
programs and then transfer into SPSS statistical software
and analyzed in SPSS Statistical software 17.0. Firstly,
general characteristics among four groups were test by
chi-square test and ANOVAs for comparability. Then,
data analysis was done by applying descriptive and
inferential statistics. For descriptive statistics; frequency,
percentage, mean and standard deviation was used to
describe the general characteristics of participants. For
Suriyan et al. 797
Edentulous patients
65-83 years
N=132
Male= 51, Female= 81
Excluded 4 senior edentulous persons
2, maxilofacial carcinoma with radiotherapy
1, retroviral infection with active pulmonary
tuberculosis
Pt rating(Satisfaction, OHQOL, QMF)
Anthropometric measurements
Blood parameters
Food diaries
1, uncontrolled type 2 Diabetes with endstaged renal failure
Random allocation
IODNEED
N=33
IOD
N=33
CDNEED
N=33
CD
N=33
Female=16, Male=17
Female=25, Male=8
Female=19, Male=14
Female=21, Male=12
Pretest
Post 1 month
Post 3 months
IODNEED
N=33
IOD
N=33
CDNEED
N=32
CD
N=33
Post 6 months
Female=16, Male=17
Female=25, Male=8
Female=18, Male=14
Female=21, Male=12
Dropout (Expired)
Female=1
OHQOL: oral health related quality of health
QMF: quality of mastication function
within-group data, compared between before and post 6
months in each group, paired t -tests were performed.
Comparison among groups, scores were compared by
one way ANOVA and if there was difference among four
groups, was analyzed by post-hoc test to know exactly
between which groups, and for equal variances Bonferoni
was used and in case of equal variance was not
assumed the Dunnett T3 was used. Comparing among
the timing of measurements (pretest, post one month,
post three months and post 6 months) and among the
four studied groups were analyzed by general Linear
Model, repeated measures. If in case of among groups,
equal variance was not assumed the Kruskal Wallis Test
was used. Cost-effective was analyzed by correlation and
regression. For nonparametric data, within groups was
tested by Wilcosin sign-rank test and among groups was
by Kruskal-Wallis test.
RESULTS
According to inclusion criteria, one hundred and thirty two
participants (81 female and 51 male) were initially
randomized into the study. There were 33 participants in
each group at baseline. All of the participants attended
post one month, post 3 months, post 6 months follow-up
appoints except one female expired in CDNEED group
due to motorcycle accident (Figure 1).
The research results found that all general
characteristics were not statistically significant difference
among the four groups; “IODNEED”, “IOD”, “CDNEED”,
and “CD" (p-value > .05). Mean scores of pretest OHIP,
QMF, VASMX, BMI, BFAT% (SFT), LBM, daily diet
intake, most of the blood parameters were not significant
different among the four groups (p-value > .05). Except
IODNEED group had significant lower mean scores in
VASMD and MNA than CD and CDNEED group.
Moreover, IODNEED group had significant higher mean
scores in Serum albumin, Serum Fe and RBC (p-value <
0.05).
As for description of mean and standard deviation of
sum of scores of oral health related quality of life (OHIP
and QMF), satisfaction scores VASMX and VASMD,
nutritional status MNA and BMI among the four groups
were elicited in Table 1. It can be seen that in IODNEED
group had from time to time improvement of mean scores
in all variables and higher than the others.
Comparison of the mean scores within group,
categorized by oral health impact profile (OHIP), quality
of mastication (QMF) , satisfaction for maxilla (VASMX) ,
satisfaction for mandibular (VASMD), pretest and post 6
months intervention, there had higher mean scores in all
four groups (p-value .001) but the best improvement of
mean difference was seen in IODNEED group (Table 2).
798 J. Med. Med. Sci.
Table 1. Descriptive statistics of OHIP, QMF, VASMX, VASMD, MNA and BMI till post 6 mos appointment
Variables
OHIP
QMF
VASMX
VASMD
MNA
BMI
IOD NEED
Mean ± SD
75.1818±19.1449
101.3030±12.1591
IOD
Mean ± SD
75.9394±18.0311
98.1515±12.1838
CD NEED
Mean ± SD
81.7576±14.2281
91.3939±13.9462
CD
Mean ± SD
81.5455±15.3401
88.8182±11.1256
105.5455±8.9620
110.4242±5.6956
108.4848±8.1590
109.5152±7.4335
96.5000±14.0919
96.9688±13.9734
92.0303±10.7746
92.2424±10.8398
68.3333±20.1117
100.606±16.5245
67.8182±17.2526
96.9697±14.7574
75.9697±16.7919
83.0909±14.0809
70.3030±15.4161
80.6364±11.5402
112.4545±13.0098
116.7576±10.5713
114.9091±12.3374
117.0303±11.0439
87.2813±14.8720
88.6875±13.9964
83.0909±11.1869
89.7879±10.5260
561.788±125.3179
682.879±63.9339
550.768±115.732
651.061±64.563
605.7576±85.1022
635.0000±76.6995
553.7879±79.2842
604.0909±67.5631
686.9697±66.9149
688.9394±64.3933
668.3333±66.9149
668.1818±67.2660
660.3125±67.8463
658.2813±70.4320
603.3333±69.7167
602.4242±67.2591
488.333±117.0781
684.546±58.1399
472.727±96.007
647.273±78.522
557.1212±100.078
596.0606±91.8623
509.6970±85.5948
569.3939±74.6843
699.8485±66.7725
721.8182±48.9231
670.3030±82.7169
702.8788±51.1742
618.1250±91.0047
620.1563±84.9714
557.8788±70.1230
558.0303±68.4076
24.5606±3.5416
27.9848±1.9704
26.3182±2.9257
27.6818±2.5459
26.1970±2.3517
27.7879±1.9962
26.7727±2.5803
28.0000±2.6428
28.5000±1.7321
28.8485±1.3721
28.4545±2.1879
28.6212±1.8583
28.0938±1.9528
28.1719±1.7808
27.6061±2.7436
27.6970±2.5798
24.3864±4.1260
24.8667±4.2778
23.7688±5.3477
24.3876±5.2485
24.9100±4.1289
25.4470±3.7145
25.1242±4.0957
24.8755±3.8426
25.3242±4.2842
25.8073±4.0734
24.6685±5.2447
25.1464±4.8420
25.6809±3.7588
25.8650±3.3889
25.1645±3.7179
25.2448±3.6540
TIMING
Pretest
1 month
3 months
6 months
Pretest
1 month
3 months
6 months
Pretest
1 month
3 months
6 months
Pretest
1 month
3 months
6 months
Pretest
Post 1 mo
3 months
6 months
Pretest
Post 1 mo
3 months
6 months
OHIP: Oral Health Impact Profile
QMF: Quality of Mastication Function
VASMX: Visual Analogue Satisfaction Score for Maxilla
VASMD: Visual Analogue Satisfaction Score for Mandibular
MNA: Mini Nutritional Assessment
BMI: Body Mass Index
Table 2. Comparison of sum of scores between pretest and post 6 months within group (Paired t-test)
OHIP
M diff
a
b
p-value
QMF
M diff
a
b
p-value
VASMX
M diff
a
b
p-value
VASMD
M diff
a
b
p-value
a
b
IODNEED
-35.2424
IOD
-33.5758
CDNEED
-15.750
CD
-10.697
< .001
< .001
< .001
< .001
-48.4242
-49.2121
-13.219
-19.485
< .001
< .001
< .001
< .001
-127.1515
< .001
-117.4242
-55.000
-48.636
< .001
< .001
< .001
-233.4849
-230.1515
-65.156
-48.333
< .001
< .001
< .001
0.001
Mean difference
Sig. (2-tailed)
Regarding nutritional (MNA, DIET, DIETITEM) and
anthropometric (BMI, BFAT% SFT, LBM) assessments,
within group pretest and post 6 months intervention,
significant higher mean differences were found in
IODNEED and CDNEED group, of the variables MNA,
daily dietary intake and BMI (p-value < .03). Moreover,
BFAT% (SFT) was non-significant lower in IODNEED
and CDNEED group (p-value >.05). On the other hand,
Suriyan et al. 799
Table 3. Comparison of sum of scores between pretest and post 6 months within group (Paired t-test)
IODNEED
-4.2879
IOD
CDNEED
CD
-2.3030
-1.922
-0.924
p-value
< .001
< .001
< .001
0.105
M diffa
-86.3636
-16.6667
-65.6250
-18.1818
p-value
<.001
.2270
.0020
.1120
DIETITEM M rankc
16.50
7.86
12.13
8.88
<.001
0.496
0.001
0.082
-1.4209
-1.3776
-0.961
-0.121
p-value
< .001
< .001
.029
.731
a
.7606
-1.6818
.3094
-.5636
0.635
0.203
0.584
0.343
-2.6667
-.8636
-1.6094
.1455
0.219
0.726
0.012
0.802
MNA
M diff
a
b
DIET
b
d
p-value
BMI
M diff
a
b
BFAT%
M diff
b
p-value
LBM
M diff
a
b
p-value
a
c
Mean difference
Mean rank
b
Sig. (2-tailed)
d
Wilcoxon Signed Ranks Test, Asymp. Sig (2-tailed)
DIET: Average mean score of seven days daily diet intake (Calories)
DIETITEM: 5 Items of Diet such as protein, carbohydrate, fat, fruits and vegetables (mixed healthy diet)
BFAT% (SFT) was -significant increase in IOD and CD
group (p-value >.05) (Table 3).
Within group comparison of the mean scores of seven
items of blood parameters between pretest and post 6
months intervention, significant higher mean differences
were found in six out of seven items in IODNEED group
(p-value < .015) and three out of seven items in CDNEED
group (p-value < ..215). Moreover, the highest mean
score differences were seen in IODNEED group (Table
4).
Regarding the comparison among groups after post 6
months intervention, General linear model repeated
measures was used to analyzed the different among
timing of measurements (pretest, post 1 month, post 3
months and post 6 months) and among the four groups
(4 ˣ 4 factors) for the variables OHIP, QMF, VASMX,
VASMD, MNA and BMI. Moreover, Univariate ANOVA
was used for daily nutritional intake, BFAT% (SFT), LBM,
and blood parameters.
The results were shown in (Table 5). (i) comparison
between “IODNEED” group and “IOD” group, there had
significant lower mean score of BFAT% (SFT), significant
higher mean scores of daily diet intake and 4 out of 7
blood parameters in IODNEED group (p-value< .05). (ii)
comparison between “IODNEED” group and “CDNEED”
group, “IODNEED” group had significant higher mean
score in OHIP, QMF, VASMD, and 4 out of 7 blood
parameters than “CDNEED” group (p-value< .02). (iii)
comparison between “IODNEED” group and “CD control
group”, “IODNEED” group had significant higher mean
score in OHIP, QMF, VASMX, VASMD, 6 out of 7 blood
parameters than “CD control group” (p-value< .016). (iv)
comparison between “IOD” group and “CDNEED group”,
“IOD” group had significant higher mean score in OHIP,
QMF, and VASMD than “CDNEED group” (p-value<
.001). (v) comparison between “IOD” group and “CD
control group”, “IOD” group had significant higher mean
score in OHIP, QMF, VASMX, and VASMD than “CD
control group” (p-value= .001). (vi) there had only
significant higher mean score in satisfaction in CDNEED
group than CD group (p-value= .007). (vii) mean scores
in MNA, BMI, were not significant different among the
groups after post 6 months intervention.
The analysis of interview timing; pretest, post 1 month,
post 3 months and post 6 months within the group: for
OHIP and QMF, it was found that pretest mean score
was significant lower than post 1 month, post 3 months
and post 6 months (p-value <0.001). Whereas, post 1
800 J. Med. Med. Sci.
Table 4. Comparison of sum of scores between pretest and post 6 months within group (Paired t-test)
Se albu
IODNEED
-.1152
IOD
CDNEED
CD
-.0242
-.0875
.0121
<.001
.498
.025
.254
-91.3333
-3.8485
-.0938
35.7272
p-value
<.001
.768
.992
.196
M diff a
b
p-value
-3.2258
.2215
-.4866
.0046
<.001
.706
.022
.993
-9.2424
.6970
-2.5938
.5152
.015
.642
.189
.582
M diff
a
b
p-value
Pl B12
M diff
a
b
Se folate
Se Fe
M diff
a
p-valueb
RBC
a
-.1776
-.0655
-.0884
-.0103
p-value
<.001
.090
.006
.429
a
-.6515
-.1697
.0531
-.2152
<.001
.013
.848
.029
0.2727
-.8939
.3906
.7061
.848
.339
.773
.369
M diff
b
Hb
M diff
b
p-value
Lympho
M diff
a
b
p-value
Serum albumin (g/L)
Plasma B12 (pmol/L)
Red blood cells ˣ10
Haemoglobin (g/L)
Total Lymphocytes ˣ 109
Serum and erythrocyte folate (nmol/L)
Serum iron (mmol/L)
12
a
Mean difference
Table 5. Pairwise comparisons among 4 groups for post 6 months(Summary).
b
Sig. (2-tailed)
Suriyan et al. 801
Table 6. Correlation between Total cost and Oral Health Related Quality of Life
Variables
2
P1 OHIP
.380a
0.145
87.799
0.001
4.689
95% CI
Lower
0.001
P3 OHIP
.497
a
0.247
91.962
0.002
6.537
0.001
0.002
<.001
a
0.377
91.302
0.002
8.842
0.002
0.002
<.001
P6 OHIP
R
R
.614
Constant
b (slope)
t
p-value
Upper
0.002
<.001
a
Predictors: (Constant) Total cost
95% CI slope “b”
month was significant lower from post 3 months and post
6 months (p-value <0.001) and also post 3 months was
significant lower from post 6 months (p-value <0.001).
Regarding the satisfaction score for mandibular, pretest
was significant lower than post 1 month, post 3 months
and post 6 months (p-value <0.001). Moreover, the post 1
month and post 3 months mean scores were significant
lower from post 6 months (p-value <0.001). For MNA,
pretest mean score was significant lower than post 1
month, post 3 months and post 6 months (p-value
<0.001), and also post 3 months was significant lower
from post 6 months (p-value <0.001). For BMI, there was
no significant different between pretest and post 1 month
mean scores but pretest mean score was significant
lower than post 3 months and post 6 months (p-value
<0.001), whereas, and post 1 month was significant lower
from post 3 months and post 6 months (p-value <0.001)
and also post 3 months was significant lower from post 6
months (p-value <0.001). Pairwise compairons within
groups and among groups for MNA and BMI are shown
in Figure 2 and Figure 3, respectively. From these
figures, it can be seen that IODNEED group had better
improvement of nutritional status from time to time.
In IODNEED group, total cost for one person was
combination of unit cost for dental implant with NEED
program cost for one person (52 baths). In the IOD
group, total cost for one person was the unit cost for
dental implant only. Same as in CDNEED group, total
cost for one person was combination of unit cost for
conventional denture with NEED program cost for one
person (52 baths) and in the CD group, total cost for one
person was the unit cost for conventional denture only.
The mean total cost in Thai Baths were in “IODNEED”
group 9565.45±792.48, followed by “IOD” group
9091.18±479.25, in “CDNEED” group 1749.78±280.35
and “Control” group 1562.36±341.99.
Regarding the analysis for cost-effectiveness in the
time period of 6 months after post intervention,
correlation between total cost and oral health related
quality of life, it was revealed that, if cost 1000 Baths
increase, there would have 1 score increased in one
month post intervention, 2 scores increased in post three
months intervention, and 2 scores increased in post six
months intervention (p-value < .001). According to mean
total cost in different studied groups, it could be
calculated that the cost-effectiveness of “NEED”
programme was (0.5 OHIP score) increased in
“IODNEED” group than “IOD” group at one month post
intervention, then (1 OHIP score) increased in
“IODNEED” group than “IOD” group at three months post
intervention. But there was no change in score increased
at post 6 months intervention than from post 3 months,
even though there had the stronger the linear relation
between the two variables, as r=.614. Also, between
CDNEED and CD group, the cost-effectiveness of
“NEED” programme in CDNEED group was (0.2 OHIP
score) increased at one month post intervention, (0.4
OHIP score) of OHIP increased at three months post
intervention than CD group. But there was no change in
score increased at post 6 months intervention than from
post 3 months, even though there had the stronger the
linear relation between the two variables, as r=.614
(Table 6).
Similarly, the cost-effectiveness of “NEED” programme
was (5.5 VASMD scores) increased in “IODNEED” group
than “IOD” group at one month post intervention, then
(6.5 VASMD scores) increased at three months post
intervention. Moreover, (8 VASMD scores) satisfaction
score for mandibular increased in “IODNEED” group than
“IOD” group at six months post intervention (p-value
<.001). Whereas, between CDNEED and CD group, (2.2
VASMD scores) increased in “CDNEED” group than “CD”
group at one month post intervention, then (2.6 VASMD
scores) increased at three months post intervention.
Moreover, (3.2 VASMD scores) increased in “CDNEED”
group than “CD” group at six months post intervention (pvalue < .001).
From (Table 7), It could be concluded that (1) if cost
1000 Baths increase there would have (2 scores)
increased in quality of mastication function in one month
post intervention (2) if cost 1000 Baths increase there
would have (4 scores) increase in satisfaction score for
mandibular in three months post intervention (3) if cost
1000 Baths increase there would have (4 scores)
increase in satisfaction score for mandibular in six
months post intervention (p-value <.001). It could be
calculated that the cost-effectiveness of “IOD”
802 J. Med. Med. Sci.
Figure 2 Pairwise compairons for MNA
Figure 3 Pairwise compairons for BMI
Table 7. Correlation between Total cost and Quality of Mastication function
Variables
R2
R
Constanta
b (slope)
t
P1 QMF
.525a
0.276
78.01
0.002
7.04
95% CI
Lower
0.002
p-value
P3 QMF
a
.733
0.538
79.72
0.004
12.295
0.003
0.004
<.001
P6 QMF
.767a
0.589
83.58
0.004
13.598
0.003
0.004
<.001
Upper
0.003
<.001
a
Predictors: (Constant) Total cost
: 95% CI slope "b"
programme and “CD” programme was (18 QMF scores)
increased in “IOD” group and (3 QMF scores) increased
in “CD” group at one month post intervention, then (36
QMF scores) increased in “IOD” group and (6 QMF
scores) increased in “CD” group at three months post
intervention. But there was no change in score increased
at post 6 months intervention than post 3 months, even
though there had the stronger the linear relation between
the two variables, as r=.767 (Table 7).
DISCUSSION
The research results found that all general characteristics
were not statistically significant difference among the four
groups; (IODNEED), (IOD), (CDNEED), and (CD). It was
the same results of other study in Canada (Morais J.A et
al., 2003).
Moreover, there were no different
between “Before program scores” of the most of the
variables among the four groups.
Comparison of mean scores between pretest and after
6 months intervention in “IODNEED” group (Paired ttest), found: mean scores for OHIP, QMF, VAS for
Maxilla, VAS for mandibular, MNA, BMI, Hip
Circumference (HC), 6 out of 7 blood parameters such as
serum albumin, plasma B12, Serum and erythrocyte
folate, serum Fe, RBC, Hb were statistically significance
higher than pretest. Moreover, lean body mass (LBM)
was increased than pretest but there was no significant
difference. It can be concluded that the senior persons
can chew meat, fruits and vegetables. On the other
hand, mean scores (BFAT%, SFT), skin fold thickness of
biceps, triceps were no significant lower than pretest. It
revealed that, the participants have knowledge and
attitude to modify their diet especially not to eat saturated
fat and intention to do light exercise such as regular
walking, yoga and light body exercise for elderly
(isometric exercise).
Comparison of mean scores between pretest and after
6 months intervention in “IOD” group, found: mean scores
for OHIP, QMF, VAS for Maxilla, VAS for mandibular,
MNA, BMI, sub-scapular and abdominal skin fold
thickness, HC, and Hb were statistically significance
higher than pretest. On the other hand, there were no
significant higher mean score of skin fold thickness (SFT)
biceps, triceps, Waist Circumference (WC), BFAT%,
LBM, serum albumin, plasma B12, Serum and
erythrocyte folate, serum Fe, and RBC. It can be clearly
seen that their skin fold thickness and body fat
percentage were higher than pretest; increase in BMI
would be due to body fat percentage. It was similar from
the study that they concluded implant subjects had
significant increases in the biceps, sub-scapular, and
Suriyan et al. 803
abdominal skin-fold thickness measurements (Morais J.A
et al., 2003). This revealed that effectiveness of surgery
had a good achievement in only better mastication
function but not increase in blood parameters and not
effective on healthier distribution of adipose tissue. It can
only be concluded that the senior persons can chew
meat, fruits, nuts and vegetables. Our finding is similar to
other studies; they reported that a significant number of
those who received the implant overdentures reported
that they had increased their intake of cheese, raw carrot,
raw apple, nuts, and bacon (Allen and McMillan, 2002).
Morais (Morais et al., 2003) confirmed that the provision
of mandibular dentures supported by 2 implants
increases food choice for individuals accustomed to
wearing conventional dentures. They find it easier to
consume hard, tough, and crisp foods, such as raw
vegetables and fruits, as well as different types of meats.
Comparison of mean scores between pretest and after 6
months intervention in “CDNEED” group, mean scores for
OHIP, QMF, VAS for Maxilla, VAS for mandibular, MNA,
BMI, LBM, 3 out of 7 of blood parameters such as serum
albumin, Serum and erythrocyte folate, and RBC were
statistically significance higher than pretest. And also
there were no significant lower mean score of BFAT%
(SFT) than pretest. This revealed that combined effect of
new CD and nutritional empowerment have better
achievement in oral health related quality of life,
nutritional status and some of the blood parameters.
In CD group, the results revealed that effectiveness of
new CD had a good achievement in only better
mastication function and oral health related quality of
health but not increase in nutritional status, blood
parameters and anthropometric measurement. It is the
same result mentioned “there was good evidence that
people adapt to tooth loss by altering their dietary intake
to compensate for the increased difficulty of eating
certain foods, even if masticatory function is restored with
conventional dentures” (Wayler and Chauncey, 1983;
Chauncey et al., 1984; Fontijn-Tekamp et al., 1996).
Pairwise comparisons among 4 groups at Post 6
months assessment, the IODNEED group had the best
significant outcomes mean scores not only oral health
related quality of life, satisfaction and mastication but also
nutritional status and blood parameters. Those finding
proved that IODNEED program was better than IOD,
CDNEED and CD. Moreover, the mean scores of oral
health related quality of life, mastication function and
satisfaction were also significantly higher in “IODNEED”
group than “CD” group and “IOD” group than “CD” group.
This could be concluded that effective of mandibular two
implant-retained over dentures was more effective in
terms of oral health related quality of life, mastication
function and satisfaction than new conventional dentures.
It was the same result with the study mentioned better
post-treatment scores for the IOD than the CD group for
general satisfaction (P<0.001) (Boerrigter et al., 1995),
significant post-treatment between group difference in
general satisfaction (P<0.005) (Thomason et al.,2003).
Furthermore, comparison between IODNEED and
CDNEED, there was significant higher mean scores in
oral health related quality of life, satisfaction for
mandibular and 4 out of 7 blood parameters. Thus, our
finding filled the gaps of other findings “prosthetic
rehabilitation in the absence of dietary counseling does
not lead to dietary improvement” (Moynihan and
Bradbury, 2001; Moynihan et al., 2006; Hildebrandt et al.,
1997; Sahyoun et al., 2003; Sheiham et al., 2001).
The results from comparisons among the timing of
assessments (within groups) revealed that there was a
steady increase in mean score of oral health related
quality of health, mastication function and mini nutritional
assessment from time to time. Regarding the mean
scores of body mass index, it remain stable between
pretest and post 1 month, then significant increase in
post 3 months than pretest, and post 6 months than post
3 months. This revealed that the longer the post
treatment duration the better improvement in BMI.
The results also shown, there are positive correlations
between cost and oral health related quality of life,
satisfaction and mastication function. From the results of
correlation and regression analysis of cost-effectiveness,
it could be clearly seen that “NEED” program had a
gradual improvement in terms of oral health related
quality of health and clients’ satisfaction. From those, it
can be concluded that “NEED” had not only improvement
in mean scores of studied parameters but also effective
by cost. Furthermore, positive correlation of cost and
effective of quality of mastication was also seen between
“IOD group and CD group” and there was 6 times
improvement of masticatory function in IOD than CD, in
our study.
All of all, NEED program can improve nutritional status
not only in mandibular two implant-retained overdentures
but also in conventional dentures.
RECOMMENDATION
Regular participatory nutritional empowerment and
isometric exercise should be provided in conjunction with
mandibular two implant-retained overdentures in Thai
senior edentulous citizens. Moreover, we have better to
provide nutritional empowerment in conjunction with
conventional dentures to whom in waiting lists or the
person who not yet suitable for IOD. Lastly, one
nutritionist should be empowered among the dental
assistances in the dental team in each treatment unit.
ACKNOWLEDGEMENT
This study was supported by the Higher Education
Research Promotion and National Research University
project of Thailand, Office of the Higher Education
804 J. Med. Med. Sci.
Commission (No. AS1148A). First of all, we would like to
thank
“THE
90th
ANNIVERSARY
OF
CHULALONGKORN
UNIVERSITY
FUND”
(Rachadaphiseksomphot Endowment Fund) for giving the
research grant. Then, we would like to thank to all
participants. Furthermore, we would like to express our
appreciation and gratitude for College of Public Health
Sciences, Chulalongkorn University, (King project)
“Project Dental Implant Honor”, Prachatipat hospital, and
BMA Bureau of Nutrition Bangkok for their supportive
efforts in this study. Moreover, we also would like to
thank to credential experts from “Project Dental Implant
Honor”, Clinical Prof. Surachai Chaiwat, Department of
Dental Surgery, Mahidol University, Assoc. Prof. Lertrit
Sarinnapakorn, Department Dental Prosthodontics,
Thammasart University, Thailand. Then, we also thank to
Assoc. Prof. Dusit Sujirarat, Head of Department of
Epidemiology, Faculty of Public Health, Mahidol
University for giving statistical comments. Lastly, we
extend our thanks to Dr. Kyaw Min (Physician), Ms.
Vatcharaporn Yaemyeesuin (Public Health nurse), Dental
assistance team in Prachatipat hospital for helping during
intervention period and data collection.
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