supported prosthesis - don t all our patients

Transcription

1 Conventional vz. implant- supported prosthesis - don t all our patients want tdental limplants? Asbjørn Jokstad Professor and Head, Prosthodontics Faculty of Dentistry, University of Toronto

2 FPDs/RPDs vs Implant prosthesis: 1. Guidance in the scientific literature?

3 FPDs/RPDs vs Implant prosthesis: 1. Guidance in the scientific literature? 2. How should we proceed when treatment planning our patients? t

4 Clinical trials on implantsupported prosthetics n =

5 Volume on implant supported prostheses (n=1986) How many have compared an implant-prosthesis prosthesis versus conventional dentures?

6 Comparison of conventional dentures vs implant-supported overdentures (4 RCTs) P I C O 2003 Groningen/ Nijmegen (Geertman, Boerrigter, Meijer, Raghoebar, etc.) Edent. mandib le i-baroverdenture (91) Conv. Denture (60) 2i-OD > CD

7 Comparison of conventional dentures vs implant-supported overdentures (4 RCTs) P I C O Edent. 2i- bar- Convent. 2i-OD > CD Groningen/Nijmegen (Geertman, Boerrigter, Meijer, mandible overdenture (91) Denture (60) Raghoebar, etc.) VA V.A. California, (Kapur, Garrett, Hamada, Roumanas, Kimoto etc.) Edent. 2-i-bar- Conv. 2i-OD mandib overdenture (37) (52) Denture > CD le

8 Comparison of conventional dentures vs implant-supported overdentures (4 RCTs) P I C O Edent. 2-imp.-- Convent. 2i-OD > Groningen/Nijmegen mandible overdenture Denture (60) CD (Geertman, Boerrigter, (91) Meijer, Raghoebar, etc.) V.A. California, (Kapur, Garrett, Hamada, Kimoto, Roumanas, etc.) Edent. mandible 2-imp.-baroverdenture (52) Convent. Denture (37) 2i-OD > CD Edent 2-imp.- Conv. 2i-OD Montreal (Awad,.man over- Denture > CD Feine, Heydecke, dible denture (48) (54) Lund, Thomason, etc.)

9 Volume on implant- supported prostheses (n=1986) How many have compared implant- prosth vs. FPDs?

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11 Volume on implant- supported prostheses (n=1986) How many have compared implant- prosth vs. RPDs?

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13 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that an implant- based prosthesis is superior to a conventional prosthesis.

14 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial?

15 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C.Patients have clear treatment preferences?

16 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C. Patients have clear treatment preferences? D. Patient recruitment to trials is difficult due to inclusion and exclusion criteria?

17 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implantbased prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C. Patients have clear treatment preferences? D. Patient recruitment to trials is difficult due to inclusion and exclusion criteria?

18 The prosthesis as a Risk factor for causing Caries Periodontitis Conve ntiona (+) - (+) - Mucosal damage, allergy, stomatitis, hyperplasia (+) - Temporomandibular dysfunction - - Prognostic factor for achieving: i Occlusal stability vz. tooth malpositions + + Bone remodeling vz. alveolar bone loss Oral comfort (esthetics, mastication, speech, etc.) + ++ Optimized food selection? + Quality of life? + Implant -prosth.

19 A. It s so obvious that an implant-based is superior to a conventional prosthesis Therefore unethical to conduct comparative trials a question of investigators t equipoise i

20 A. It s so obvious that an implant-based is superior to a conventional prosthesis Therefore unethical to conduct comparative trials a question of investigators equipoise Hypothesis: Patients will prefer implant solutions if they are properly and adequately informed

21 Clin Oral Implants Res 2003; 14: &

22 Clin Oral Implants Res 2003; 14: & But even too much information will also confound patients. e.g. when recruiting patients for trials

23 Explaining possible Risks and Discomforts (excerpt from a study protocol approved by Ethics Committee) 1. Risks associated with surgery and placement of dental implants: Including, but not limited to, bleeding and bruising Post-surgical pain Temporary speech problems Delayed healing Post-surgical infection Bone fracture Loss of alveolar ridge Osteomyelitis Damage to opposing dentition Chronic pain Local or systemic infection Abscess Oroantral or oronasal fistula Sequestrum Haematoma Gingivitis Transient or permanent damage to the nerves in the jaw

24 So what then is the best approach to present, and discuss complex treatment that includes an element of risk?

25 Best approach to present and discuss complex treatment? Look in the communication sciences, i.e. in the social sciences, - literature

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27 Best approach to present and discuss complex treatment? Answers to be found in the social sciences 3 domains to be addressed: Perceived technical competence Interpersonal manners Communication skills

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31 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C. Patients have clear treatment preferences? D. Patient recruitment to trials is difficult due to inclusion and exclusion criteria?

32 Jokstad A, Brägger U, Brunski JB, Carr AB, Naert I, Wennerberg A Quality of Dental Implants Int Dent J, 2003; 53 Sup 2: & Int J Prosthodontics 2004; 17:

33 FDI statements Paper and list

34 We must begin to apply the WHO ICIDH-2 terminology when reporting outcomes in dentistry/prosthodontics No /Mild /Moderate /Severe /Complete impairment of functions: Taste - Proprioceptive Touch - Articulation - Ingestion - Mobility of joint - Muscle power No /Mild /Moderate /Severe /Complete difficulty to: Speak Eat - Drink - Basic interpersonal interactions- Complex interpersonal interactions - Recreation and leisure

35 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C. Patients t have clear treatment t t preferences? D. Patient recruitment to trials is difficult due to inclusion and exclusion criteria?

36 Don t all patients want to be treated with dental implants?

37 Palmqvist N=3000, Need: Edentate: t 8% et al., COIR 1991 Rand.pop. questionn aire (45 69 ) Edentate one jaw:17% RPD users: 23% (45-69 yrs) Dentate: t 51%

38 Salonen, N 150 Only 15% would Commun Dent Oral Epidemiol 1994 N=150 Interview (55yrs, new dentures) consider implant treatment Palmqvist et al., N=3000, rand.pop. Need: Edentate: 8% COIR 1991 questionnaire (45-69 yrs) Edentate one jaw: 17% RPD users : 23% Dentate: 51%

39 Berge, COIR 2000 N=3500, Rand.pop. questionnaire (15-85 yrs) 23% would not consider implant treatment Salonen, N=150 Interview Only 15% would consider CDOEpi 1994 (55yrs, new dentures) implant treatment Palmqvist et N=3000, rand.pop. Need: Edentate: 8% al., COIR questionnaire (45-69 yrs) Edentate one jaw: 17% 1991 RPD users : 23% Dentate: 51%

40 Kronström N=2276, pop. Need: DK S et al., Clin questionnaire (55-69 yrs) Edentate 20%30% Imp Dent Few teeth miss.: Rel Res 2002 RPD users: Berge, COIR N=3500, 23% would not consider implant 2000 rand.pop. treatment Salonen, CDOEpi 1994 Palmqvist et al., COIR 1991 questionnaire (15-85 yrs) N=150 Interview (55yrs, new dentures) N=3000, rand.pop. questionnaire (45-69 yrs) Only 15% would consider implant treatment Need: Edentate: 8% Edentate one jaw: 17% RPD users: 23% Dentate: 51%

41 ow then can we conduct RCTs?

42 Use RCT study designs that take patient preferences into consideration Trials taking patient preferences into account provide, in theory, more reliable indicators of patient-centered outcomes than ordinary RCTs

43 RCT study designs that take patient preferences into consideration 1979: Zelen single consent 1985: Olschewski/Scheuren comprehensive cohort design 1989: Brewin and Bradley partially rand. pat.-pref. design 1989: Rücker 1990 Zelen double consent two stage trial design 1991: Korn & Baumrind 1993: Wennberg g( (design) 2005 : Millat ea. Surgical eval. design

44 but what if we provide the implants for free?

45 36% still refused

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47 Zero trials comparing FPDs/RPDs vs implant-supported prostheses reasons? A. It s so obvious that t an implant-based prosthesis is superior to a conventional prosthesis? B. No research funding since the medical condition and its treatment seems trivial? C. Patients have clear treatment preferences? D. Patient recruitment to trials is difficult due to inclusion and exclusion criteria?

48 E.g. RPD: contraindications Contraindications (more harm than benefit likely): Oral health care compromised Active oral infection & -inflammation

49 RPD: poor prognosis Contraindications: Oral health care compromised, infection/inflammation Contraindications: Oral health care compromised / infection & - Poor inflammation prognosis Poor prognosis General factors General factors Not able to adapt to prior prosthesis; length of time Not able since to extraction adapt to prior >5 years; prosthesis; patient length attitude of to time treatment; since extraction etc. >5 years; patient attitude to treatment; etc. Stomatognathic factors Stomatognathic factors Inadequate vertical space; oral hygiene, etc. Inadequate vertical space; oral hygiene, etc. Intra-oral factors Intra-oral factors Narrow, low or flat residual ridge; low tuberosity, Narrow, hyperplastic low or tissue, flat residual bony spikes, ridge; tori, low etc. tuberosity, hyperplastic tissue, bony spikes, tori, etc. Individual tooth factors Individual tooth factors > 1mm mobility, no vitality, > 5mm pocket depth; short, 1mm conical mobility, roots; no vitality, incisors, 5mm isolated pocket teeth; depth; etc short, conical roots; incisors, isolated teeth; etc

50 Implant prosthetics: contraindications Contraindications: Vital anatomical structures Active skeletal growth Active infection & inflammation General surgical contraindications Serious mental illness Systemic diseases likely to compromise implant surgery

51 Implant prosthetics: contraindications & poor prognosis Contraindications: Vital anatomical structures Active skeletal growth Active infection & inflammation Serious mental illness Systemic diseases likely to compromise implant surgery Poor prognosis :unless special amendments Insufficient bone Insufficient vertical space Previous radiation therapy of head & neck Skeletal discrepancies Type IV bone Poor prognosis :uncertain impact? Current or past history of drug/alcohol abuse Extensive tobacco use Poor oral hygiene Severe bruxism or clenching

52 Conclusion why no RCTs? We can conduct comparative studies in theory, but 1. who are the patients that would be indifferent to receiving a conventional prosthesis instead of an implant based prosthesis?...and 2. would they be representative for the population?... and 3. are there any dental researchers today who have genuine equipoise?

53 1. What do we know? 2. How should we proceed when planning treatment for our patient?

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55 Treatment planning The patient s circumstances 1. Identify the patient s opinions, choice of values and treatment goals The evidence The patient s wishes

56 Treatment planning 1. Identify the patient s opinions, choice of values and treatment goals 2. Adequate patient communication: Three critical domains Interpersonal manners Perceived technical competence Communication skills

57 Treatment e planning patient s circumstances The 1.Patient s opinions, choice of evidence values and treatment goals The The patient s wishes 2. Patient communication 3. Consideration of possible technical solutions

58 Choice of technical solution?

59 Choice of technical solution?

60 Cast partial denture Clinical knowledge Prosthesis design Prognosis Retention

61 Acrylic partial denture Clinical knowledge Prosthesis design Prognosis

62 Crowns + cast partial denture Additional clinical knowledge 36 extraction or crown? Soldered ? Milled crowns? Intra- or extracoronal attachments?

63 Fixed bridge Clinical knowledge Conventional alloy, titanium-ceramic or gold acrylic? Zn-phosphate, GIC or resin cement? Bridge extension 46? 46+47?

64 Conus bridge Clinical knowledge: 47, 36, 45: extraction gold coping attachment? 43/44/45: separation?

65 Implant retained prosthesis Clinical knowledge One / two implants? Wide collar - standard diameter? Splintet - non-splintet FPD? Cement / screw-retained? Nobelbiocare, AstraTech, 3i, Endopore, Straumann, Friadent?

66 Treatment planning The patient s circumstances Overwhelming task to appraise and present evidence without first communicating with the patient! The evidence The patient s wishes

67 Treatment e planning The patient s circumstances 1. Patient s opinions, choice of values and treatment t t goals 2. Patient communication 3. Consider possible technical solutions 4. Present realistic outcomes with different technical solutions The evidence The patient s wishes

68 Treatment e planning 1. Patient s opinions, choice of values and treatment goals 2. Patient communication 3. Consider possible technical solutions 4. Present realistic outcomes in respect to treatment aim with different technical solutions Restore function? Change appearance? Prevent future problems? + Level of, or risk for, iatrogenic damage

69 Reality can occasionally be Perfect result %? Opacity due to misalignment %? Gingivalretraction %? Exposed fixture %? Adjacent necrosis %?

70 Independent variables Age group Gender Male Female Material Amalgam Composites Glass ionom. Dentists #1 #2 Location Bivariate Bivariate 95% significance odds ratios Confidence intervals bivariate odds ratios ** *** - ** - NS *** - NS Multi-variate odds ratios Multivariate significance - ** *** - ** - NS ** - NS 95% Confidence intervals for multivariate odds ratios % years Mandible København Aarskursus Mars 2000 Maxilla 1.55 * * Risk factors Longevity Outcomes probabilities %? %? gingivitt 5. Reach consent amongst the alternative technical solutions Dentist:patient relationship Two-way communicationtechnical solutions %? %? KR År København Aarskursus Mars 2000 København Aarskursus Mars 2000 QOL København Aarskursus Mars 2000 Cost (Fee+Incremental) Worst Case Scenario

71 Treatment planning - take-home messages 1. Two-way communication is critical in the treatment t t planning phase. Be cognizant of importance of: Interpersonal manners Perceived technical competence Communication skills

72 Treatment planning - take-home messages 1. Two-way communication is critical in the treatment planning phase. Be cognizant of: Interpersonal manners, Perceived technical competence & Communication skills 2. Dentists t and patients t diverge about evaluation of therapy success appraisal of, and attitude towards risk

73 Treatment planning - take-home messages 1. Two-way communication is critical in the treatment planning phase. Be cognizant of: Interpersonal manners, Perceived technical competence & Communication skills 2. Dentists and patients diverge about evaluation of therapy success & appraisal of, and attitude towards risk All treatment suggestions must therefore be individualized and based on the patient s wishes and values

74 Thank you for your kind attention

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