My Critical appraisal is of The Evaluation of patient experience and satisfaction with CAD-CAM-fabricated complete dentures: A retrospective survey study was written by [Saponaro et al (2016)] This study was published in Volume 116 issue 4 in October of 2016 by The Journal Of Prosthetic Dentistry.
The author’s focus is of the retrospective survey of Computer-aided design, Computer-aided manufacture (CAD-CAM) construction of Complete Dentures in comparison with conventional techniques.
A Cohort study was employed in order to find outpatient preferences and satisfaction in relation to complete denture construction by way of a questionnaire issued retrospectively to the patient post-treatment.
The study produced by Saponaro et al shows patient preference and satisfaction by means of a questionnaire introduced retrospectively post-treatment.
The hypothesis being that patients whose treatment was by means of digital complete dentures would be satisfied with their brand-new complete dentures.
During the period of this study being published, there was a shortage of sound, evidence-based reports of the treatment outcomes of CAD-CAM Complete Dentures
For the purpose of this analysis, the utilization of guidance from the CASP Cohort appraisal study checklist was used in order to assist in the critical appraisal of this paper.
Did the study address a clearly focused issue?
The authors were not clear on the focus of the survey. In the first instance, they determined that the purpose of the survey was to ‘asses patient preferences and satisfaction’ they went on to say that patients rated their ‘overall outcome and experience’ and later that they were evaluating ‘patient experience and satisfaction’
This causes confusion as the description of what the authors are seeking changes throughout the paper.
Was the cohort recruited in an acceptable way?
Before the study was underway, approval was obtained from The Ohio State University Biomedical Sciences Institutional Review Board (protocol 2014H0024)
The authors opted to use the assistance of a computer software; Windent EE provided by Carestream Dental, dental database search rather than manually searching patient records.
Informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization were obtained for the survey portion on the study.
The inclusion criteria were for patients with edentulism, who had sought prosthodontic treatment in The Ohio State University College of Dentistry Clinics using Avadent, a computer-based digital Complete Denture fabrication system with the only exclusion criterion to the study was that patients were not to have required immediate digital Complete Dentures.
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By only using one exclusion the patient selection is flawed due to poor choice selection, the election to use only one exclusion may have been to maximize the results of the search. But this neglected to exclude patients that may have had other underlying health issues.
Choosing to exclude more than one factor could have provided more appropriate results for the purpose of the study and would have prevented the need to disregard implant-based restoration at a later date.
A total of 50 patients who were treated with Cad-Cam fabricated complete dentures, were identified in 3 different clinics.
- The Predoctoral Comprehensive care clinic.
- The Advanced Prosthodontics clinic.
- Dental Faculty practice clinic.
An overall total of 50 patients could be seen as a small number, however, all the candidates were selected from the Ohio University clinics, had the patient selection been on a national or statewide scale a higher number may have been included.
A number of ‘no response’ questionnaires should have been considered, arguably a higher number of patients would have generated far more completed questionnaires.
The patients were split evenly between males and females, aged between 26 and 90 years old, with a median age of 62.64 years old.
With 25 males and 25 females, the selection was an unbiased representation of both sexes. However, the age limit was quite wide, with several of the candidates having been non-experienced denture wearers. Non-experienced wearers would have no comparative experience of the two differently constructed prosthesis.
Was the exposure accurately measured to minimize bias?
The 50 patients were split evenly between males and females with a broad range of ages. This prevents bias towards sex and age.
The results of the questionnaire relating to patient satisfaction were evaluated using descriptive statistics. The statistical tests were performed using SAS (v9.1.3; SAS Institute Inc)
With the findings of the questionnaires recorded and analyzed using the Mantel-Haenszel chi-squared test, for comparison of the qualitative data.
A decision was made to eliminate implant-based dentures from the results, an updated participation percentage is not shown, this can be seen as a bias towards success by not supplying all relevant information.
The patients were selected within Postdoctoral and Predoctoral clinics indicating the potential for the patients to not have received the same treatment due to a variety of differing experience. It could be considered that Predoctoral treatment can have limitations due to the inexperience of the student clinicians attending clinics compared with qualified professionals.
The issue of bias is not eliminated the patient selection appears to be unbiased, but the results favor success.
What confounding factors have the authors accounted for?
It is pointed out in the survey that there was a relatively low number of patient responses (n=19) there was an attempt to contact the patients who had not answered the questionnaires, but a low number remained.
The authors suggest, that the low number of returns may have been because of the dissatisfaction with the overall experience of complete dentures.
The authors also agree that the response options of Agree, remain neutral, or disagree with the statements were severely limited and that they may have misled the patients into a selection that they were not completely in agreement with.
What confounding factors have the authors not accounted for?
A higher number of initial patients could have helped to maximize the return of questionnaires due to un-responsive patients or a longer case-controlled study, using a group of conventional Complete Denture wearers compared to that of digital.
Another confounding issue is that of the patients’ age, the survey included patients up to the age of 90, elderly patients can often have memory recall issues being unable to remember how their old conventional dentures were. “the aging process engenders difficulty in encoding and subsequently remembering medical information” (Kessels, 2003)
Was the follow up of subjects complete and long enough?
The questionnaire listed 10 questions, 6 of these were comparison questions the other 4 were general.
Of the 6 comparison questions, 14 of the 19 patients had the ability to answer the questions due to previously wearing a denture, the other 5 patients were new denture wearers and would not be able to make a judgment on questions that were comparing different denture manufacture procedures.
The remaining 4 questions could be answered by all the patients.
The median age of the returned questionnaires was 65.3 years old. Within the 19 returned questionnaires the range for prosthesis use was between 1 and 26 months, 3 of the patients had only had the prosthesis fitted for 3 months or less. The median time of fitment is 21 months.
The patients with a lower number of months post-fitment may not yet have experienced any issues with their completed prosthesis. Longer term study could have allowed any issues both technical and clinical to surface.
Were the patients treated equally?
The patients all exhibited with the same condition, the need for Complete Dentures, but they were treated with clinicians with differing knowledge and experience.
The differing knowledge and experience could indicate inconsistent treatment approaches for individual patients.
Implant cases were excluded from the results for the need for the standardization of the results.
The patients although indicative of the same requirement may have been treated differently during visits to the surgeries because of the varying levels of experience provided in the 3 different clinics.
What are the results of this study?
A response rate of 38% of the 50 participating patients was achieved.
The majority of the received Questionnaires agree on Cad-Cam Complete Dentures being the ‘Best‘ outcome, but that experienced Complete Denture wearers rehabilitated with Cad-Cam fabricated Complete Dentures Could not differentiate between their previous conventionally constructed Complete Denture and their new Cad-Cam Complete Denture although overall positive ratings were received for the digital Complete Dentures.
Patient satisfaction was recorded with percentages and in agreement to the following:
- 78.95% That they were pleased with the aesthetics of their denture.
- 78.57% That their new digital Complete Dentures were “better” than their previous set of Complete Dentures.
- 73.68% Were satisfied with their new complete dentures
- 68.75% That their new complete dentures were easy to clean
- 68.42% Found their new dentures to be “comfortable” and would recommend digital Complete dentures to others.
- 57.89% Found that their speech and chewing abilities had improved.
- 52.63% Of Complete Dentures fit well and stay in place during function.
How precise were the results?
Many variables were included in the patient selection and treatment, the result is biased towards success.
With some of the group being identified as previously not wearing a denture the comparison questions would not have been answered resulting in questionnaires not being returned, causing the median age of the returned questionnaires to be 65.3 years old.
Participation refusal was ignored, with the results based solely on the 38% participation level.
Had different questions been asked, or a more appropriate patient selection occurred the results could have been vastly different
Do you believe the results?
Although the results do seem to be indicative of a positive outcome, the results are questionable.
The results show as being positive, but only 38% of the 50 selected patients responded with only the responsive questionnaires were taken into consideration, this steers towards a bias in favor of Cad-Cam fabricated dentures.
The survey is sufficiently flawed due to the question’s raised and the restricted answers available.
Are the results of the trial valid?
The results of the trial are not as valid as they could have been as the study has been aimed towards perceiving digitally designed Complete Dentures in a positive manner.
Cad-Cam technology seems to be advancing at the same rate worldwide. This study was conducted between 2012 and 2014. It is now 2018, technology, especially in this specialist area, has moved on in considerably.
Will the results help locally?
The results of this survey can help locally as the findings were all from patients requiring Complete Dentures, this is comparable to having a survey in another region with the same requirement.
The cases were sourced from a Hospital/University setting comparative to Dental Hospital setting that I currently work under, in the United Kingdom.
Working within an NHS environment has brought about a requirement for a reduction in the need for clinical visits in order to relieve the strain of a demanding service.
Do the results of this study fit with other available evidence?
The Study has noted that a reduction in the number of appointments can be achieved with Digitally constructed Dentures. Jeneva et all (2018) agrees with this ‘it can be concluded that the main advantages of CAD/CAM dentures are the reduced clinical chair time and the number of visits”
Over half (52.63%) of the survey agree that the complete dentures fit better than conventionally manufactured an article written by Steinmassl et al (2018) confirms: “CAD/CAM produces dentures with a better fit than conventional denture”
- Kessels, R. (2003) Patients’ memory for medical information. JOURNAL OF THE ROYAL SOCIETY OF MEDICINE [online]Volume 96 p.220. Available at: https://journals.sagepub.com/doi/pdf/10.1177/014107680309600504 [Accessed 12th December. 2018]
- Elencevska, S. Janeva, N. Kovacevska, G Lazarevska, B. Mijoska, A and Panchevska, S. (2018) Advantages of CAD/CAM versus Conventional Complete Dentures – A Review. Open Access Macedonia Journal of Medical Sciences. [online] Volume 6 (issue 8) p.1498-1502. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6108805/ [Accessed 12th December. 2018]
- Dumfahrt, H. Gruner, I. Steinmassi, O and Steinmassi, P. (2018) CAD/CAM produces dentures with improved fit. Clinical Oral Investigations. [online] Volume 22 (issue 8) p.2829-2835. Available at: https://link.springer.com/article/10.1007%2Fs00784-018-2369-2 [Accessed 12th December. 2018]