Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 892899

Subjective values of different treatments for missing molars

in older Japanese
K. IKEBE, T. HAZEYAMA, R. KAGAWA, K. MATSUDA & Y. MAEDA

Department

of Prosthodontics and Oral Rehabilitation, Osaka University Graduate School of Dentistry, Yamadaoka, Suita, Osaka, Japan

SUMMARY The purpose of this study was to determine how elderly Japanese people subjectively
value treatment options for missing molars. Subjects
were 528 independently community-dwelling
elderly people. They were presented with photographs and descriptions of the process and expected
outcomes of five possible treatment options: cantilever fixed dental prosthesis (FDP); resin or metal
removable partial denture prosthesis (RPDP);
implant-supported fixed prosthesis; and no replacement (shortened dental arch: SDA) for missing
lower bilateral first and second molars. The participants filled in the questionnaire on subjective
importance for treatment and indicated on a visual
analogue scale how they valued the treatment
(utility value: UV). Values were analysed by Mann
Whitney U-tests and multiple logistic regression
analyses. Overall, the UVs for the FDP and the metal
RPDP were the highest, and the UV for the SDA was
the lowest. With respect to subjective importance,
chewing ability and no pain during function were

Introduction
In treatment decisions, both the health care professionals and the patients play an important role. The decision
of whether and how to treat a patient depends upon the
balance among the perceived advantages, such as selfimage, aesthetics or enjoyment of eating, as well as the
disadvantages, such as invasiveness, treatment period,
possible side effects or treatment cost. It is now
generally accepted, especially for chronic medical conditions, that a patient-oriented system for clinical
decision-making leads to greater success than a doc 2010 Blackwell Publishing Ltd

significantly selected more frequently. Multiple

logistic regression analyses showed that the UV for
the resin RPDP had significant positive associations
with denture wearers and low treatment cost,
whereas the implant had significant negative associations with denture wearers and older age. The
SDA had significant positive associations with men
and low treatment cost and a negative association
with appearance. In conclusion, these elderly Japanese preferred cantilever FDPs and metal RPDPs to
implants and no replacement. It suggests that the
SDA as an oral health goal can be questionable from
the patients point of view, even if it is biologically
correct.
KEYWORDS: treatment
options, missing molars,
removable partial denture prosthesis, cantilever
fixed dental prosthesis, shortened dental arch,
implant, subjective value, visual analogue scale
Accepted for publication 2 June 2010

tor-oriented system (1, 2). Thus, it is believed that the

patients values and preferences should take a central
role in the clinical decision-making process (3).
Utility is a general concept for measuring the value
individuals attach to the consequences of various
courses of action (4). The utility approach is now a
viable alternative for investigators to use in measuring
health-related quality of life (5). Although the concept
of the utility value (UV) and formal methods of
incorporating utility measurements into evidencebased practices (6) are widely accepted in medicine,
applications to dentistry have been relatively limited.
doi: 10.1111/j.1365-2842.2010.02123.x

SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

This concept is important, especially for prosthodontics,
because oral rehabilitation with prostheses aims to
enhance quality of life rather than to eradicate disease.
Historically, several treatment options for missing
molars have been proposed, including a removable
partial denture prosthesis (RPDP), a cantilever fixed
dental prosthesis (FDP) or, recently, an implant-supported prosthesis. The conventional belief that posterior
missing teeth should be replaced with a prosthesis as
soon as possible has been disputed by several researchers because improvement of oral functions by prostheses is unclear and such prostheses may cause many
types of oral diseases (79). There appears to be a trend
in favour of the use of the shortened dental arch (SDA)
concept or implant-supported restorations instead of
conventional RPDPs, given the evidence that the longterm use of RPDP is associated with increased risk of
caries and periodontitis and low patient acceptance
(10). This suggests that an SDA is an important strategy
to avoid over-treatment and side effects of tooth
replacement. In addition, some studies in Western
countries found that the SDA with 20 teeth is aesthetic,
functional and acceptable to patients and remains stable
over time (11, 12).
However, dietary habit, sense of well-being, economic status and the social security system of each
country vary remarkably and significantly influence
clinical decisions regarding treatments. Additionally,
the selection of treatment options by patients is usually
influenced by age, gender, dental status, financial status
and the individuals appreciation of oral health.
The purpose of this study was to determine how
elderly Japanese people value resin and metal RPDPs, a
cantilever FDP, an implant-supported prosthesis or no
replacement for missing molars. Additionally, we evaluated the agreed-upon treatment in relation to the
subjective factors that were a part of the individuals
decision-making process.

Materials and methods

The study protocol was approved by the Institutional
Review Board of the Osaka University Graduate School
of Dentistry. All subjects gave written, informed consent prior to participation.
The participants in this investigation were community-dwelling, independently living elderly people.
They were participants of the Senior Citizens College
of Osaka prefecture who voluntarily attended lectures
2010 Blackwell Publishing Ltd

once a week. This college, which enrols volunteers for a

period of 1 year and is supported by the government of
Osaka prefecture, is part of the adult education system
for those over the age of 60. Total subjects were 528
individuals (237 men and 291 women), and their mean
age was 660 years (SD 42).
First, participants filled in the self-administered
questionnaire that requested information about sociodemographic variables such as age; gender; self-assessed
general health; satisfaction with financial status; educational level; and their present dental status (complete
denture, removable partial denture prosthesis or
natural dentition). Participants were divided into a
removable denture group and a natural dentition
(dentate) group, including those with fixed prostheses.
In this study, a clinical case involving missing
bilateral lower first and second molars (13) was
presented to all the participants. All the maxillary teeth
and the other mandibular incisors, canines and premolars were assumed to be intact. All participants were
interviewed and presented with photographs of five
possible options (Appendix 1). The treatment processes,
time periods, conceivable side effects, coverage by
National Health Insurance and expected outcomes
were explained with wording based on the paper by
Nassani et al. (13) and modified in the context of the
actual situation in Japan (Appendix 2). The four
treatments with prostheses, in addition to the option
of no-treatment, were as follows:
1 An acrylic-resin-based RPDP (resin RPDP).
2 A cobaltchromium-based RPDP (metal RPDP).
3 A conventional cantilever FDP (cantilever FDP).
4 An implant-supported FDP (Implant).
5 No treatment: an SDA without replacement (SDA).
Only resin RPDPs were coverable by the Japanese
National Health Insurance. The cantilever FDP was
assumed to use two abutments of the first and second
premolars and replaced one missing molar.
To measure the UV (13) of each treatment, participants were asked to indicate on a standardized visual
analogue scale how they would rate treatments of their
own mouths if they had received each of the treatments. The visual analogue scale was a 100-mm
horizontal line with two clear end points. The left end
point represented the worst option, which they would
not want. On the other end of the line, the right end
point represented the perfect option, which they would
want. A UV of 0 represented the worst possible
treatment, and a UV of 100 represented the best.

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K . I K E B E et al.

Results
The average UV of all the treatment options for all
subjects was 477  350 (SD). Overall, the UVs for the
cantilever FDP and the metal RPDP were the highest,
and the UV for the SDA was the lowest (Fig. 1). The
UVs were significantly different between treatment
options except for between the cantilever FDP and the
metal RPDP, according to the Friedman test and the
pairwise comparisons. Between any dichotomized
groups, such as between men and women or between
important and unimportant decision-making items, the
rank orders of the UVs were not remarkably different.
*SPSS Inc., Chicago, IL, USA.

100

80

Utility value

60

40

20

SD
A

pl
an
t
Im

ev
er
F
til
C
an

al
R
PD
P
et
M

D
P

0
R
PD
P

Additionally, participants were asked to select three

of six values in accordance with what they considered
important for the treatment of their missing molars. The
six items presented were no pain during function, less
invasive to a natural tooth, chewing ability, speaking
ability, appearance and low treatment cost.
Data analyses were conducted using SPSS Version
140 for Windows*. Because the UVs were not normally
distributed, non-parametric tests were used for the
statistical analyses. The MannWhitney U-test was used
for the comparisons of the UVs of each treatment
between the two groups, for example, denture and
dentate groups. To compare the UVs of the five
treatment options, the Friedman test was used for
statistical analyses. Pairwise comparisons were made
using the Wilcoxon test with a Bonferroni correction.
P-values of <005 were considered to be statistically
significant.
Finally, because the UV is a multifactorial condition,
multiple logistic regression analyses were used in tests
of the independent variables relationship with the
dichotomous dependent variables after controlling for
other factors. The dependent variables were the UVs of
each treatment option. The participants were dichotomized by splitting at the median of the UVs of each
treatment option, such that the higher half was equal to
1 and the lower half was equal to 0. For these analyses,
independent variables were age (6069 years and
70+ years), gender (women and men), dental status
(dentate and removable denture) and important items
for decision-making (unimportant and important).
Independent variables were entered into the model by
a stepwise method at a significant level of 005.

R
es
in

894

Fig. 1. Average and standard deviation of UVs of all treatment

options. Overall, the UV for the cantilever FDP and the metal
RPDP were the highest, and the UV for the SDA was the lowest.
The UVs were significantly different between treatment options
except between the cantilever FDP and the metal RPDP, according
to the Friedman test and pairwise comparisons.

With respect to the subjective importance for the

replacement of missing molars by the participants,
chewing ability (858%) and no pain during function
(717%) were significantly selected more frequently
than the other options (the second column in Table 1).
The other items were selected by 387279% of the
total participants.
In bivariate analyses (Table 1), the older group
(70 years and over) rated the resin RPDPs significantly
higher and rated implants significantly lower than the
younger group (6069 years). Women rated the SDA
significantly lower than men. Removable denture
wearers placed a higher value on RPDPs. In contrast,
dentate subjects valued implants and the SDA without
replacements higher than the denture wearers. Participants giving importance on low treatment cost rated
both resin RPDPs and SDAs significantly higher and
rated implants significantly lower than did subjects for
whom low cost was less important. Also, participants
giving importance on appearance rated cantilever FDP
significantly higher and rated resin RPDPs significantly
lower. Participants giving importance on less invasive
to a natural tooth rated cantilever FDP significantly
lower than the counterparts.
In multiple logistic regression analyses (Table 2), the
UV for the resin RPDP had significant positive associations with individuals wearing dentures and impor 2010 Blackwell Publishing Ltd

SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

Table 1. Comparison of the utility value for each treatment option between two groups in relation to age, gender, dental status and
important factors for treatment

Resin RPDP
% of
subjects Mean SD
Total
100
Age
6069
807
70+
193
Gender
Male
450
Female
550
Dental status
Dentate
615
Removable denture
385
Chewing ability
Important
858
Unimportant
142
No pain during function
Important
717
Unimportant
283
Low treatment cost
Important
387
Unimportant
613
Less-invasive to a natural tooth
Important
341
Unimportant
659
Appearance
Important
315
Unimportant
685
Speaking ability
Important
279
Unimportant
721

Metal RPDP
P-value Mean SD

521 333

Cantilever FDP
P-value Mean SD

582 311

Shortened dental
arch

Implant

P-value Mean SD

613 310

P-value Mean SD

419 351

P-value

253 316

499 336
619 302

**

575 308
608 322

ns

610 308
642 307

ns

436 348
347 357

263 322
226 298

ns

550 299
500 357

ns

572 286
593 328

ns

608 297
619 320

ns

411 336
422 363

ns

286 319
227 313

434 329
643 303

**

549 307
631 314

**

606 303
615 327

ns

454 347
360 350

**

285 335
186 269

**

526 336
490 312

ns

581 314
592 291

ns

619 310
570 307

ns

425 356
380 320

ns

238 311
343 335

513 335
542 328

ns

595 306
548 325

ns

613 311
614 307

ns

411 348
439 361

ns

254 320
249 307

ns

596 291
474 349

**

590 292
578 322

ns

620 296
609 318

ns

382 324
442 366

292 321
227 311

531 327
515 337

ns

624 293
561 318

ns

529 309
657 301

**

423 351
416 352

ns

256 311
251 320

ns

441 348
559 319

**

565 329
591 303

ns

659 294
591 315

462 367
398 342

ns

221 316
268 316

ns

518 334
522 333

ns

549 336
595 300

ns

633 306
605 311

ns

425 364
416 347

ns

275 341
245 307

ns

ns, no significance; FDP, fixed dental prosthesis; RPDP, removable partial denture prosthesis.
MannWhitney U-test **P<005, *P<001; bold numbers are mean values with a significant difference.

tance on low treatment cost and a negative association

with importance on appearance. The UV for the metal
RPDP significantly associated with individuals wearing
dentures, and the UV for the cantilever FDP had a
negative association with importance on being less
invasive to a natural tooth. The UV for the implants had
significantly negative associations with individuals
wearing dentures and older age. The UV for the SDA
had significantly positive associations with men and
importance on low treatment cost and a negative
association with importance on appearance.

Discussion
Perceptions of health and disease, subjective needs
and preferences for treatments vary among patients
2010 Blackwell Publishing Ltd

with the same condition. Thus, treatments should

also be designed on an individual basis according
to the patients needs and demands (14). It is
important to recognize how patients of a certain age
and of a specific dental state rate various treatment
options.
Overall, the rank of the UVs of each treatment option
was similar between dichotomized groups. Participants
placed the highest value on the cantilever FDP, not only
in dentate individuals but also in denture wearers;
however, individuals who highly rated less invasiveness
to the natural teeth valued cantilever FDPs less than did
the other individuals. Obviously, oral comfort is more
effectively achieved using fixed rather than removable
restoration (10), which seems to be a reason for the
higher preference of the cantilevered FDP.

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K . I K E B E et al.
Table 2. Logistic regression model for the utility values of each treatment option by a stepwise method

Dependent variables

Independent variables

Resin RPDP

se

P-value

Odds
ratio

95% Confidence
interval

Dental status (denture)

Appearance
Low treatment cost
Sensitivity: 745; Specificity: 571

132
)055
060

021
022
021

<0001
0013
0004

376
058
183

249
038
121

567
089
277

Metal RPDP
Dental status (denture)
Sensitivity: 674; Specificity: 468

060

019

0002

182

124

267

Cantilever FDP

Less invasive to a
natural tooth
Sensitivity: 448; Specificity: 758

)093

020

<0001

039

026

059

Implant

Age
Dental status (denture)
Sensitivity: 529; Specificity: 621

)059
)048

026
020

0021
0015

055
062

033
042

091
091

SDA

045
)045
046

020
021
020

0021
0031
0024

156
063
158

108
042
106

233
096
236

Gender (male)
Appearance
Low treatment cost
Sensitivity: 658; Specificity: 530

Dependent variable: utility value for each treatment; Independent variables: age (6069 years = 0, 70+ years = 1), gender (female = 0,
male = 1), dental status (dentate = 0, removable denture = 1) and important items selected (unimportant = 0, important = 1), RPDP,
removable partial denture prosthesis; FDP, fixed dental prosthesis; SDA, shortened dental arch.

In our previous study (15), most dentists rated

cantilevered FDPs lower than implant-supported prostheses because FDPs require a sacrifice of healthy
enamel and dentine, which goes against the recent
minimal intervention concept. In this study, participants were more concerned with chewing ability and
the absence of pain during function while being less
concerned with the preservation of natural teeth.
Because dentists had a professional background in and
were more informed about the biological disadvantages
of preparing abutment teeth, their preference to their
own oral status should be taken into consideration. The
minimal intervention concept is expected to be widely
accepted by Japanese patients, although it is not yet at
this moment.
This study also confirmed that RPDPs remain an
adequate and economical treatment option. Indeed,
removable denture wearers preferred an RPDP as
opposed to the preference of non-wearers, suggesting
the satisfaction of denture wearers with their current
situation. It has been reported that patients who are
given dentures sometimes bother to wear them and are
usually satisfied with oral function and appearance
(16). On the other hand, dentate individuals tended not
to accept an RPDP, which might show prejudice on the

part of those who have never had to wear dentures.

Acrylic-resin-based RPDPs, which are covered by the
Japanese National Health Insurance, were preferred by
participants who placed importance on low treatment
cost.
In our previous study (15), most dentists selected an
implant-supported prosthesis as an optimal treatment
in consideration of comfort, function and biological
cost. However, these implants were not desired by the
elderly, especially among the older group and those
with removable dentures. The findings of this study
reconfirmed the notion that a patients treatment
selection should take into account not only expectations of a successful treatment but also consideration of
risk factors and treatment cost. Implants are often not
an optimal treatment option in terms of cost-effectiveness and with regard to the risk of side effects. Walton
et al. (17) indicated that over a third of mandible
edentulous patients did not choose to receive a chargefree treatment for implant-supported overdentures,
which suggests expense is not the only impediment to
implant treatment. Choices involving surgery may
cause anxiety and uncertainty, especially for older
people (17). They may be more conservative in their
outlook, accept living with physical imperfections and
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SUBJECTIVE VALUES OF TREATMENTS FOR MISSING MOLARS

have more concerns about their health than younger
patients.
When patients have a chronic condition, particularly
when alternative therapies exist, they want treatment
to be cost-effective, rather than just accepting what the
therapist deems significant. Actual costs and insurance
availability are key themes to emerge as important
factors in the decision-making process. Because financial resources are limited for most of people, especially
in the pensioner, cost-effectiveness must be influencing
the determination of type of dental treatments. It is safe
to say that the economic status was associated with
higher UV of resin RPDP and lower UV of implant in
senior group.
Kayser and his colleagues (18) criticized the conventional morphological-oriented approach to the treatment of tooth loss and suggested that such an approach
could lead to over-treatment. They therefore proposed
the SDA as a treatment option. Treatment with RPDPs is
non-invasive to the remaining dentitions structure, but
RPDPs can increase the risk of caries, periodontitis and
residual ridge reduction, particularly in distal extension
areas. In such patients, an SDA approach is a wellprecedented treatment option (10). It was reported that
a moderate SDA had little, if any, impact on occlusal
stability, tooth loading, temporomandibular disorders,
interdental spacing, periodontal disease, patients comfort or masticatory performance (11, 12, 19).
Previous surveys of dentists attitudes in several
European countries indicated that the SDA concept
was accepted by a great majority of dentists but not
widely practiced (20). We believe it is similar among
Japanese prosthodontists, although we have no evidence. In the Netherlands, qualified members of
restorative dentistry were of the view that the SDA
concept has a useful place in clinical practice and
judged the outcome of SDA management to be generally satisfactory or at least sufficient; however, they
applied the SDA concept on a regular or at least
occasional basis to <10% of patients in their practices
(21). Similarly, in members of the European Prosthodontic Association, 96% of respondents agreed that
the SDA concept was acceptable in clinical practice.
However, 72% of respondents had treated fewer than
50 patients in this way over the previous 5 years (22).
A possible reason for the discrepancies between
attitudes of dentists and actual clinical practice is the
economic incentive for dentists to treat with prosthodontics options (20). If missing teeth are untreated,
2010 Blackwell Publishing Ltd

dentists do not gain economically. The question of the

SDA becomes less one of effectiveness of treatment and
more one of finances (23).
Only one study in the United Kingdom (13) surveyed
how patients value the outcomes from different treatments for the SDA. The UVs were the following: cobalt
chromium based RPDP: 042; acrylic-resin-based RPDP:
049; implant treatment: 053; resin-bonded cantilevered bridge: 063; conventional cantilevered fixed
bridge: 064; and no treatment: 028. The researchers
concluded that the patients placed a very low value on
the outcome from no treatment. They also stated that
this finding undermines the view of the WHO and the
UK Department of Health, both of which have suggested that 20 standing teeth is an appropriate goal for
oral health (13).
Participants of this study also placed the lowest value
on the SDA without replacement, especially in women
and participants who placed an importance on appearance. In contrast, individuals emphasizing low treatment cost tended to accept the SDA. This observation
was in line with a previous report in the United
Kingdom (13). One possible reason for the lowest value
on no replacement is that supraeruption of unopposed
posterior teeth, and movement of teeth adjacent to
posterior tooth loss have been emphasized in Japanese
dental education. In addition to a dentists recommendation, another reason may be that the Japanese
National Health Insurance covers RPDPs. Therefore,
patients tend to have a sense of their right to have the
prostheses. As a result, only a minority of people with
loss of teeth remain untreated. Indeed, in our previous
survey (not published) of 44 community-dwelling older
Japanese with missing bilateral mandibular first and
second molars, 37 patients (84%) were using the
RPDPs, although this may be an uncommon phenomenon except for Japan. At any rate, the appropriateness
of the SDA as a goal of a prosthetic treatment, even if it
is biologically correct, can be questionable from the
patients point of view in Japan. Further investigations
into the value of the SDA in relation not only to
functional but also to psychological effects are needed.
The enhancement of the quality of life through a
specific prosthetic treatment cannot be assumed to be
the same for every patient, even though an improvement has been described for many patients (24).
It is important to recognize the limitations of this
study. The study population comprised urban Japanese
individuals who attended the Senior Citizens College

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K . I K E B E et al.
courses. Therefore, they might be considered healthier,
better educated and more financially secure than the
average older adult in Japan. Most of our subjects had
finished high school (89%), and many had at least a
college degree (37%). This is a higher educational level
than that of the average Japanese in the national
survey for the same generation, which reported that
82% had finished high school and 24% had a college
degree (25). Only 69% of the subjects reported dissatisfaction with their present financial status and only
40% of the subjects evaluated their quality of life as
poor, suggesting that they might be a more middle-class
group than would be found in the general population.
Therefore, the study population was comparatively
more concerned with oral health and could spend
more money for dental treatment than the average
person. These situations possibly influenced the results
of this study. Consequently, the results reported here
may be specific to this study sample and should be
generalized by confirming these associations in other
studies of a variety of populations.
The most important confounders in prosthetic treatment studies may be the dentist him herself and the
applied treatment principle (26). We recognize that our
own biases regarding treatment could lead the subjects
in a certain direction, although we tried to explain each
treatment as fairly as possible with a written description
based on a previous study (13). In addition, clinical
decisions are inherently associated with considerations
of cost-effectiveness when health budgets are limited
(6). As stated, the treatment period and estimated
expenses were explained to the participants; however, a
more detailed description of individualized treatment
would be needed in an actual clinical situation.

Conclusions
Among elderly Japanese people, a cantilever FDP and a
metal RPDP were valued the highest, according to
individual UV scores, while an SDA was the least
valued. The factors influencing the choices of one
treatment option over another varied. The denture
wearers rated the value of RPDPs highly, while dentate
individuals did not. Implants had a significantly negative association with individuals wearing dentures and
individuals of older age, and an SDA had a significantly
positive association with men and with the self-rated
importance of treatment cost. The study suggests that
older Japanese adults generally prefer a fixed prosthe-

sis, while removable denture wearers prefer a removable denture. At present, the SDA without replacement
of missing molars as an oral health goal is questionable
from the patients point of view even if it is biologically
correct.

Acknowledgments
This research was supported by a Grant-in-Aid for
Scientific Research (No. 19390496, principal grant
holder: Kazunori Ikebe) from the Japan Society for
the Promotion of Science.

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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1 How you would value the health of
your mouth if you had the type of treatment described?
Appendix S2 Questionnaire (original in Japanese).
Please note: Wiley-Blackwell are not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than
missing material) should be directed to the corresponding author for the article.
Correspondence: Kazunori Ikebe, Department of Prosthodontics and
Oral Rehabilitation, Osaka University Graduate School of Dentistry, 1-8
Yamadaoka Suita Osaka 565-0871, Japan.
E-mail: ikebe@dent.osaka-u.ac.jp

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