1 Volume 23 2024 e243318 Original Article Braz J Oral Sci. 2024;23:e243318http://dx.doi.org/10.20396/bjos.v23i00.8673318 1 Department of Dentistry, State University of Ponta Grossa, Ponta Grossa, Paraná, Brazil. Corresponding author: Dr. Nara Hellen Campanha Campus Uvaranas, Avenida General Carlos Cavalcanti n° 4748, Bloco M, Sala 64ª Ponta Grossa, Paraná, Brazil, CEP: 84030-900 Phone: +55-42-3220-3104, Fax: +55-42-3220-3102 E-mail: narahell@yahoo.com.br Editor: Dr. Altair A. Del Bel Cury Received: May 2, 2023 Accepted: August 18, 2023 Self-perceived oral health: a study with patients wearing removable dentures Solange Schroeder Corrêa1 , Poliana Alexandra Martinello1 , Dominique Ellen Carneiro1 , Alfonso Sánchez-Ayala1 , Nara Hellen Campanha1* Aim: This study aimed to investigate the relationship between self-perceived oral health and the prosthetic status of individuals who seek care in prosthodontics clinics. Methods: Self-perceived oral health was analyzed through the Geriatric Oral Health Assessment Index (GOHAI). Abutment tooth mobility was assessed, and denture status was determined by clinical assessment of stability, retention, occlusal balance, vertical dimension, and integrity of dentures. The frequency of individuals in each variable was determined for the low and very low GOHAI conditions. Chi-square, Pearson, and stepwise logistic regression tests were used for the statistical analyses (α = 0.05). Results: Ninety wearers of removable dentures with a mean age of 55.1±9.1 years were evaluated. None of the variables was related to GOHAI values (p > 0.05). The regression analysis showed that age predicts (p = 0.006) the variation of GOHAI conditions (OR = 0.924, CI = 0.873- 0.978), showing only 7.6% protective effect against very low GOHAI. Unsatisfactory stability showed the opposite effect (p = 0.034) and the individuals with this characteristic are more likely (OR = 3.055) to have very low GOHAI scores (CI = 1.085- 8.602). Conclusions: The self-perceived oral health of wearers of removable dentures worsens with age and unsatisfactory stability of dentures. Keywords: Self concept. Oral health. Dental prosthesis. Rehabilitation. https://orcid.org/0000-0001-8736-8243 https://orcid.org/0000-0002-6041-1587 https://orcid.org/0000-0002-4865-5394 https://orcid.org/0000-0003-3426-0997 https://orcid.org/0000-0002-9915-1591 2 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 Introduction Despite the advent of new forms of dental treatments and materials as well as oral health prevention strategies, edentulism is still prevalent in the Brazilian pop- ulation (3.9%) and significantly higher than the global mean (2.3%), according to Kassebaum et al1. (2014). Although edentulism is not exclusive of older people, it has been related to the ageing of the population1. Tooth loss gradually generates a decrease in the ability to select and grind food due to changes in oral stereognosis or in the ability to distinguish physical characteristics of food2, and in masticatory movement control resulting in the loss of periodontal affer- ents responsible for sensory feedback3. Thus, the masticatory performance is altered due to the decrease in the occlusal area where the force generated by the masticatory muscles is applied4, implying increased swallowing and number of masticatory cycles required to compensate for an inefficient masticatory function5. Moreover, the occlu- sal instability produced by tooth loss can determine the posterization of condylar positioning6 and greater risk of signs and symptoms of temporomandibular disorder7. Tooth loss can also cause problems in social interactions, shame, and social embar- rassment, due to phonetic and masticatory difficulties, physical appearance, and the presence of pain, generating possible emotional disorders8. Oral rehabilitation using complete dentures (CD) or removable partial dentures (RPD) is intended to replace lost teeth by restoring occlusal support and an efficient masticatory function9,10 and can restore the patient’s lost confidence after tooth loss11-13.CD or RPD can be considered the first choices of prosthetic treatment due to their cost-effectiveness ratio14. They are non-invasive alternatives for treatments involving attachments, conventional fixed dentures, and implant-supported or implant-retained dentures15. The successful performance of CD or RPD is influenced by prosthetic factors such as retention, stability, support, and longevity of the materials16. Physiological factors, such as age, decreased sensitivity of the mucous, and less capacity for transmitting masticatory force through artificial teeth may reduce the satisfaction and adapta- tion17 and consequently the success of CD or RPD. The satisfaction of individuals with removable dentures has been associated with aes- thetics, personality, physical and social adaptation16. The self-perception of individuals rehabilitated with CD or RPD is fundamental for the success of the treatment13. The General Oral Health Assessment Index (GOHAI) was developed to measure self-per- ception of oral health and can even be considered as an indicator of oral-health related quality of life (OHRQoL), measuring oral difficulties that affect patients with a remov- able prosthesis in three dimensions: physical functions, psychological functions, and pain and discomfort18. According to the values obtained based on the responses to the questionnaire, individuals can be categorized as presenting low, moderate, and high self-perception of oral health19. However, although the GOHAI has been used to determine the need for rehabilita- tion treatment19, the evidence on which of the prosthetic factors affect it most is still 3 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 limited and there is no consensus regarding the association of some factors with OHRQoL19-22. Thus, this study aimed to investigate the relationship between self-per- ceived oral health and the prosthetic status of individuals who seek care at the Remov- able Prosthesis Clinic of the State University of Ponta Grossa. The null hypothesis of this study is that the individual’s self-perception of oral health is not influenced by the prosthetic status. Material & Methods Sample This cross-sectional study included a convenience sample composed of wearers of removable dentures who seek care at the Removable Prosthesis Clinic of the State University of Ponta Grossa. The study was developed for four months. Individuals who had good general health, complete or partial edentulism, and who had at least one type of removable denture (CD or RPD) in one of the jaws were considered to participate. The exclusion criteria were the presence of systemic disease or neuro- muscular disability (reported in the patient’s anamnesis). This study was approved by the Research Ethics Committee of the State University of Ponta Grossa, under Opin- ion 13/2010, protocol number 13319/09. Patients who were accepted to participate were submitted to examination for application of inclusion or exclusion criteria, and all volunteers received instructions about the evaluation procedures and signed a free and informed consent form. Assessment of Self-perception of OHRQoL – GOHAI instrument The approach and clinical evaluations of the patients were carried out individually. Data collection was performed by a single duly trained examiner, under artificial light. The validated Brazilian version of GOHAI was applied23. For each of the twelve questions in the questionnaire, the answer options that the individuals provided were cataloged as: always, sometimes, or never. Each answer was given a score: 1 for “always”, 2 for “sometimes” and 3 for “never”. The sum of the scores for each patient was obtained. The higher the sum was, the better the individual’s self-perceived oral health. Values ranged from 12 to 36, in which a range of 34 to 36 was considered high, between 31 and 33 moderate, and less than 30 low. Oral characteristics Clinical data were collected to verify the type of removable dentures (CD or RPD), number of abutment teeth, tooth mobility, occlusal balance, vertical dimension of occlusion, stability, retention, and integrity of removable dentures. For RPD, the mobility of the abutment teeth was measured with Periotest® (Siemens, Gulden-Medizintechnik, Bensheim, Germany), without the denture in the oral cavity. The Periotest® pen was placed perpendicular to the buccal face of the abutment tooth, close to the center of the crown. When there were carious lesions or resto- ration, the tip of the pen was directed laterally towards a healthier dental structure, as recommended by the manufacturer. Periotest® provides a Periotest® Value (PTV), which ranges from -8 to 50, representing dental mobility. These values were 4 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 converted to the Miller index ranging from 0 to 3, as follows: 0: perceptible but not quantifiable mobility (PTV = from -8 to 9), 1: perceptible mobility (PTV = from 10 to 19), 2: mobility up to 1 mm in a horizontal direction (PTV = from 20 to 29), and 3: mobility > 1 mm in any direction (horizontal, vertical, rotation; PTV = from 30 to 50)24. Prosthetic status The prosthetic status was analyzed with the dentures positioned in the oral cav- ity. The stability of the CD was considered satisfactory when only light movements were obtained by light bilateral digital pressure in the premolar region. The stability of the RPD was satisfactory if there was no movement when gentle digital pressure was applied. The retention of the CD was considered satisfactory if the prosthesis remained in place during a moderate mouth opening. The retention of the RPD was satisfactory if the clamps provided resistance to the removal of the denture in the opposite direction to the insertion. The occlusal balance was considered satisfac- tory if the prostheses did not move when occluding slowly. The vertical dimension was determined based on facial harmony, being categorized as very low, acceptable, and very high. The loss of integrity or apparent structural defect of the dentures was considered if they had broken flanges, missing or fractured teeth, or loss of large frag- ments of the base18. Statistical analysis The data were explored using the IBM® SPSS® Statistics 20 program, and all sta- tistical inferences were performed with two-tailed operations assuming a signif- icance level of 5%. The intra-examiner agreement was moderate for the variable mobility (Kappa = 0.5), high for retention (Kappa = 0.7) and GOHAI (Kappa = 0.8), and perfect for stability, occlusal balance, vertical dimension, and integrity of the den- tures (Kappa = 1.0). The frequency of individuals in each category of variables was determined for the conditions of low (≥ 24) and very low (< 24) GOHAI scores (value dichotomized using median splits)25. The Chi-square test was conducted to associate the GOHAI conditions to categorical variables – sex, type of removable prosthesis, abutment mobility, and stability, retention, occlusal balance, vertical dimension, and integrity of the prosthesis. For this purpose, the final values of the variables stability, retention, and integrity were determined considering the condition of the dentures in both jaws. To compare the type of removable dentures with the GOHAI conditions, the Chi-square test was adjusted for all pairwise comparisons in the rows of each inner- most sub-table using the Bonferroni correction. The condition of each dental arch (upper or lower) was categorized as rehabilitated with CD or RPD or dentate/edentulism without any prosthesis. The presence of abutment mobility was recorded if the individual had a degree greater than or equal to 2 for this variable in any of the jaws26. After checking for normal distribution using the Shapiro-Wilk and analyzing the skewness and kurtosis parameters (-2 - +2), the numerical variables GOHAI, age and number of abutments were correlated to very low GOHAI values using the Pearson’s test. Binary logistic regression analysis was used to assess the influence of the investigated variables on the presence of very low GOHAI. Initially, the Enter method was applied to analyze all variables in an input 5 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 block using a single step. Backward stepwise selection was then applied based on Wald’s statistical probability. Thus, at each step, the least significant variable was removed until all the remaining variables made a significant contribution to the regression model. Results The sample consisted of ninety individuals aged 38-80 years (mean age = 55.1 ± 9.1 years). Sixty-two patients were female. In the sample, 85 individuals (94.4%) pre- sented low GOHAI, and 06 patients (5.6%) showed medium or high GOHAI. As a methodological resource, the cutoff point (< or ≥ 24) for the conditions of low and very low GOHAI was determined considering the median split (24.7) of all values obtained25. When analyzing the characteristics of the individuals in each GOHAI cat- egory (Table 1), none of the variables in isolation showed any significant relationship with the GOHAI values (p > 0.05). Table 1. Frequency of variables according to GOHAI conditions (n = 90). Categorical variables Low GOHAI Very low GOHAI Statistical n = 56 n = 34 n % n % X2 p Sex 0.549 0.459 Female 37 41.1 25 27.8 Male 19 21.1 9 10.0 Maxillary occlusal status 0.283 0.868 CD 34 37.8 21 23.3 RPD 17 18.9 11 12.2 Absence of prosthesis 5 5.6 2 2.2 Mandibular occlusal status 5.424 0.066 CD 9 10.0 4 4.4 RPD 23 25.6 7 7.8 Absence of prosthesis 24 26.7 23 25.6 Stability 2.979 0.084 Poor 12 13.3 13 14.4 Satisfactory 44 48.9 21 23.3 Retention 0.588 0.810 Poor 36 40.0 21 23.3 Satisfactory 20 22.2 13 14.4 Occlusal balance 0.071 0.790 Poor 33 36.7 21 23.3 Satisfactory 23 24.5 13 14.4 Continue 6 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 Continuation Vertical dimension 1.765 0.184 Very low 14 15.6 13 23.3 Acceptable 42 46.7 21 14.4 Very high 0 0 0 0 Prosthetic integrity 0.071 0.790 Present 25 27.8 21 23.3 Absent 31 34.4 13 14.4 Mobility 0.610 0.435 Present 6 6.7 2 2.2 Absent 50 55.6 32 35.6 Numerical variables Mean SD Mean SD R p Age 57.0 9.5 52.0 7.5 0.202 0.057 Number of abutments 1.89 2.1 1.24 1.5 0.159 0.135 SD: Standard Deviation CD: Complete Dentures RPD: Removable Partial Dentures The logistic regression analysis showed that age was a variable capable of signifi- cantly predicting (p = 0.028) the variation in GOHAI conditions (Table 2). However, age covered only 7.2% of the protective effect against very low GOHAI. For the variable unsatisfactory stability, the effect was the opposite (p = 0.042), showing that individu- als with this characteristic were more likely (OR = 4.395) to present a very low GOHAI. This model showed 85.7% specificity (ability to classify individuals in the category of low GOHAI), and 61.8% sensitivity (ability to recognize individuals with a very low GOHAI), presenting a correct overall classification rate of 76.7%. After applying the step-by-step method (Table 3), the variables mentioned above were again the only ones were able to predict a variation in GOHAI condition. Age (p = 0.06) again showed a 7.6% protective effect, and individuals with unsatisfactory stability (p = 0.034) presented greater chance of having very low GOHAI (OR = 3.055). The specificity of the model increased to 87.5%, but the sensitivity decreased to 35.3%, and the correct overall classification rate was 67.8%. Table 2. Logistic regression model for very low GOHAI using the Enter method (n = 90). Explanatory variables B2 SE3 Wald p Odds ratio 95% confidence interval Age* -0.075 0.034 4.853 0.028 0.928 0.868 – 0.992 Sex -0.001 0.595 0.000 0.998 0.999 0.311 – 3.209 Maxillary occlusal status CD –– –– 0.416 0.812 –– –– RPD -0.574 1.282 0.201 0.654 0.563 0.460 – 6.943 Absence of prosthesis 0.224 1.406 0.025 0.873 1.251 0.800 – 19.666 Continue 7 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 Continuation Mandibular occlusal status CD –– –– 0.805 0.669 –– –– RPD -0.795 0.887 0.804 0.370 0.452 0.079 – 2.569 Absence of prosthesis -0.349 1.209 0.083 0.773 0.705 0.066 – 7.542 Number of abutments1 -0.365 0.449 0.661 0.416 0.694 0.288 – 1.673 Poor stability 1.480 0.727 4.143 0.042 4,395 1.056 – 18.286 Poor retention -0.273 0.712 0.147 0.702 0,761 0.189 – 3.073 Poor occlusal balance -0.406 0.798 0.259 0.611 0.666 0.139 – 3.182 Very low vertical dimension 0.424 0.605 0.491 0.483 1.528 0.467 – 5.002 Absence of prosthetic integrity 0.651 0.570 1.302 0.254 1.917 0.627 – 5.865 Present mobility -0.188 1.147 0.027 0.870 0.828 0.087 – 7.848 Constant 4.132 2.245 3.388 0.066 62.285 –– 1. Numerical variables. 2. B = partial regression coefficient. 3. SE = Standard Error. *Statistical difference CD: Complete Dentures RPD: Removable Partial Dentures Table 3. Logistic regression model for very low GOHAI using the Backward Wald method (n = 90). Explanatory variables B2 SE3 Wald p Odds ratio 95% confidence interval Age1 -0.079 0.029 7.505 0.006 0.924 0.873 – 0.978 Poor stability 1.117 0.528 4.472 0.034 3.055 1.085 – 8.602 Constant 3.484 1,539 5.123 0.024 32.575 –– 1. Numerical variables. 2. B = partial regression coefficient. 3. SE = Standard Error. Discussion This study aimed to determine the factors that have the greatest influence on the vari- ation in self-perception of oral health of patients wearing removable dentures, espe- cially prosthetic factors. The variables did not show any relationship with GOHAI when analyzed in isolation. This can be explained by the fact that self-perceived oral health involves a multidimensional concept that reflects an individual’s oral conditions at a given time and that also depends on previous experiences27, similarly to the quality of life, which is also influenced by multiple factors28. Thus, oral health can be influenced by proper prosthetic and physical factors such as age and sex, but in integral compre- hensive way, and not by the action of just one specific factor. Cultural, psychological, educational, dietary, and financial factors can interact with the mentioned factors28,29 and influence GOHAI scores. 8 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 Age was one of the variables that influenced the variation in GOHAI scores. Oliveira et al.30 (2020) (mean age of 77 years), on the other hand, did not find a relationship between GOHAI values, the use of dentures, and age. The mean age in our study was 55 years, and age was not an exclusion criterion, and therefore the results are likely influenced by the exclusion criteria. Netuveli et al.31 (2006) say that the quality of life can increase with aging, but this relationship cannot be analyzed in isolation, since financial situation, functional limitations and social living are also factors that influ- ence the quality of life. Individuals with unsatisfactory stability were more likely to have very low self-percep- tion of oral health (OR = 3.055), and this was the only prosthetic factor that influenced GOHAI values. The stability of removable dentures implies resistance to displacement when it is subjected to functional stress in the horizontal and rotational directions32. Cosme et al.33 (2006) determined that the correspondence between chewing, stability, and comfort is related to the satisfaction of users of removable prostheses after five years of use. Inoue et al.34 (2011) found that aesthetics and stability had a minimal effect on the quality of life of patients with RPD. The possible influence of stability on oral health can be explained by considering that this parameter depends mainly on the quality of the adjustment in the abutment teeth and remaining tissues32, which can gradually decrease over time. The preservation of the remaining tissues is also an important factor in the longev- ity of removable dentures9. Poorly adapted CD with no occlusal balance modifies the distribution of forces on the residual ridge, resulting in greater bone resorption, or may eventually contribute to base fractures due to fatigue in the acrylic resin35. The greater the stiffness of the retentive system of the RPD, the lower is the transmission of loads to the fibro-mucosa and alveolar ridge. However, the tension generated in the remaining abutment teeth is also greater, which can, in the long run, damage the periodontium36 or the metal framework by fatigue37. In RPD, an adequate design of the metallic infrastructure and mainly of the type of direct retainer can guarantee stability, despite the possible fatigue of the metal alloys and wear of the acrylic resin of the bases33. In CD, stability can be affected mainly by the degree of residual ridge resorption, which can be considered the factor that most affect the degree of dissatisfaction with treatment29. Yet, poorly adapted dentures can lead to flaccidity, due to bone resorption or mucosal hypertrophy, which can directly affect stability38. Differences in the self-perceived oral health of users of removable dentures in the same status can be explained by possible adaptive events in different ranges that promote the gradual learning of new patterns of muscle movement, determining neu- roplastic changes in the sensory-motor facial cortex39. Chen et al.39 (2012) showed that there is a relationship between stability, retention, tongue support, and oral health in patients with CD. The tongue is a multifunctional muscle that acts synergistically with the facial and cervical muscles during speech, chewing, and swallowing. Thus, the tongue can also act as an adjunct factor in the retention and consequent stability of removable dentures. 9 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 In patients who wear mucosa-supported dentures and teeth-mucosa-supported den- tures, whose stability can be affected by residual ridge resorption over time, as an alter- native, conventional fixed implants, implant-supported, or implant-retained overden- tures can provide greater satisfaction to wearers of CD with very resorbed ridge due to the greater stability and retention offered40. Moreover, the use of implant-supported fixed dentures can offer greater masticatory function and masticatory performance and OHRQoL throughout the time of use41. Individuals with implant-supported or retained prostheses are more satisfied than those with conventional removable den- tures, and this dental treatment is able to promote the well-being of people with low socioeconomic scores in public health care42. In this study, the age and stability of dentures had a protective factor against low self-perceived oral health, indicating that the null hypothesis must be rejected. The subjects participating in this study (comprising patients who sought oral rehabili- tation at the university clinic). The authors hypothesized that the research subjects would be dissatisfied with their current removable dentures, presenting conse- quently low GOHAI values, since sociodemographic (e.g. income and schooling), prosthetic, and oral characteristics (e.g. occlusal pairs) are variables that inter- fere with self-perception22. GOHAI values were predominantly very low or low. The present results should be interpreted with caution, considering that a convenience sample was used in this study, that is, subjects were not chosen through random selection. Therefore, these results should not be extrapolated or be considered rep- resentative of all of wearers of removable dentures and/or seeking treatment for oral rehabilitation. Further studies simultaneously evaluating the number of occlusal pairs, masticatory performance, swallowing threshold, and stereognosis may offer a better insight into the relationship between oral health and prosthetic status of individuals who seek care, and a more objective comparison of self-perceived oral health. The inclusion of a larger number of individuals in the present study could have offered greater discrim- ination on the type of removable dentures. However, the regression models employed offer an acceptable capacity to recognize the factors that significantly influence the variation in GOHAI (76.7% and 67.8%). The remaining percentage of influence may be related to the variables mentioned above, complementing the model. Considering the conditions in which this study was developed, it can be suggested that the low self-perception of oral health in patients with removable prostheses wors- ens with age and with unsatisfactory denture stability. Acknowledgments This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal do Nível Superior – Brazil (CAPES) – Finance Code 001, and in part by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Conflict of interest None. 10 Corrêa et al. Braz J Oral Sci. 2024;23:e243318 Data availability Datasets related to this article will be available upon request to the corresponding author. Author contribution Solange Schroeder Corrêa: Methodology, validation, formal analysis, investigation, data curation, writing – original draft preparation and reviewing, visualization. Poliana Alexandra Martinello: Methodology, validation, formal analysis, data cura- tion, writing – original draft preparation and reviewing, visualization. Dominique Ellen Carneiro: Formal analysis and writing and reviewing. Alfonso Sanchez Ayala: Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing – original draft preparation and reviewing, visualization. Nara Hellen Campanha: Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing – original draft preparation and reviewing. All authors approved the final version of the manuscript. References 1. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of severe tooth loss: a systematic review and meta-analysis. J Dent Res. 2014 Jul;93(7 Suppl):20S-8. doi: 10.1177/0022034514537828. 2. Ikebe K, Amemiya M, Morii K, Matsuda K, Furuya-Yoshinaka M, Yoshinaka M, et al. 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