Minimising mechanical prosthodontic interventions for adult patients with a shortened dental arch in South Africa

Khan, Saadika (2017-12)

Thesis (PhD)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY : Background: A large body of high-end evidence suggests that shortened or posteriorly reduced dental arches (SDA or PRDA) are adequate for oral function. Such a finding has positive implications for patients from resource-constrained communities. Indeed, in the context of South Africa (SA), the SDA or PRDA concept has been embedded within its oral health policies since 1994, although no context-specific evidence appears to have informed this policy. The SDA concept, considered as a non-interventionist therapeutic approach, may be seen as a significant evidence-based primary healthcare solution for the underprivileged and underresourced majority of SA, when applied appropriately. The cost of current prosthodontics interventions, including removable, fixed or implantretained prostheses are very high and not within the reach of the underprivileged majority. These prosthodontic appliances are not constructed at public health clinics and patients may only obtain these from dental teaching institutions and private practitioners. From a human rights perspective, evidence-based research should guide practitioners and their practices as it can ensure patients’ right of access to healthcare and the appropriate use of beneficial evidence whilst eliminating harmful ones. This stance has been made more explicit within the amended National Oral Health Strategy of SA. Objectives: To determine the effectiveness (viz. oral function, patient satisfaction and OHRQoL) of a SDA or PRDA compared to a complete dental arch, with a view to minimizing expensive prosthodontic interventions for the South African partially dentate adult community. Methods: A step-wise approach in study designs was implemented amongst a South African cohort. A systematic review, followed by an overview of systematic reviews was conducted to guide researchers with the literature, and in turn provide a scaffold for the cross-sectional questionnaires and cross-sectional clinical study for this cohort. Studies were conducted among dental practitioners, clinical teachers, and dental students to determine what was currently taught and clinically practiced. A randomized controlled trial was subsequently conducted to determine patient satisfaction and quality of life with a SDA or PRDA. Results: Studies conducted were from the top-end of the hierarchical evidence pyramid; thus their results are expected to have evidence of strong reliability and validity with respect to the benefits of the SDA or PRDA. The generalizability of outcomes obtained related to settings, subject, intervention, results and costs which were acceptable for this cohort. Aspects of knowledge translation (KT) such as diffusion (creating awareness of the SDA concept) and dissemination (publishing and conference presentations of the different research studies) were fulfilled. Conclusions: This step-wise research approach highlighted the absence of the implementation aspect of KT, namely the application of the SDA or PRDA concept to clinical practice. The implication of this on the potential to positively impact patients’ treatment costs, satisfaction and oral health-related quality of life within the SA context, is noteworthy. The evidence obtained and presented strongly questions the current non evidence-based aspects of prosthodontic curricula such as rehabilitation to complete arch status at the largest dental teaching institution in Africa. Moreover, the efficiency of the system is based on informed healthcare policies, emphasizing the need for evidence-based research both at an institutional and private practice level. Additionally, the contextual evidence derived from the research performed towards the present PhD highlighted key areas that may be grouped into important human rights, academic and economic aspects of all those who are impacted.

AFRIKAANSE OPSOMMING : ‘n Groot aantal hoë-end bewyse dui daarop dat verkorte of posterior verminderde tandbogen (VT of PVT) voldoende is vir mondelinge funksie. So ‘n bevinding het positiewe implikasies vir pasiënte uit hulpbronbeperkte gemeenskappe. In die konteks van Suid-Afrika (SA) is die VT - of PVT-konsep inderdaad in sy mondgesondheidsbeleid sedert 1994 ingebed, hoewel geen konteks-spesifieke getuienis hierdie beleid ondersteun nie. Die PVT-konsep, wat beskou word as ‘n nie-intervensionele terapeutiese benadering, kan gesien word as ‘n belangrike bewys-gebaseerde primêre gesondheidsorg oplossing vir die minderbevoorregte meerderheid van SA, wanneer dit toepaslik toegepas word. Die koste van huidige prostodontiese ingrypings, insluitend verwyderbare, vaste of inplantaatbevestigde prosteses, is baie hoog en nie binne die bereik van die minderbevoorregte meerderheid nie. Hierdie prostodontiese toestelle word nie by openbare gesondheidsklinieke aangebied nie en pasiënte kan dit slegs by tandheelkundige onderwysinrigtings en privaat praktisyns ontvang. Uit ‘n menseregte perspektief moet getuienis-gebaseerde navorsing praktisyns en hul praktyke rig, aangesien dit pasiënte se reg op toegang tot teopaslike en voordelige gesondheidsorg verseker, terwyl skadelike praktyke elimineer word. Hierdie houding is meer eksplisiet gemaak binne die gewysigde Nasionale Mondgesondheidstrategie van SA. Doelwitte: Om die effektiwiteit (nl. Mond funksie, pasiënttevredenheid en mondgesondheidverwante lewensgehalte) van ‘n VT of PVT te bepaal in vergelyking met ‘n volledige tandheelkundige boog, met die doel om duur prostodontiese intervensies vir die Suid-Afrikaanse gedeeltelik dentate volwasse gemeenskap te verminder. Metodes: ‘n Stewige benadering in studieontwerp is onder ‘n Suid-Afrikaanse kohort geïmplementeer. ‘n Sistematiese oorsig, gevolg deur ‘n oorsig van sistematiese resensies, is gedoen om navorsers met die literatuur te lei en op sy beurt ‘n steierwerk vir die dwarssnitte-vraelyste en kruis-seksie-kliniese studie vir hierdie kohort te verskaf. Studies is onder tandheelkundige praktisyns, kliniese onderwysers en tandheelkundige studente gedoen om te bepaal wat tans onderrig en klinies toegepas word. ‘n Gekontroleerde proef is gevolglik uitgevoer om die pasiënttevredenheid en lewensgehalte met ‘n VT of PVT te bepaal. Studies wat uitgevoer is, was van die top-einde van die hiërargiese bewyse-piramide; dus word verwag dat hulle resultate bewyse het van sterk betroubaarheid en geldigheid ten opsigte van die voordele van die VT of PVT. Die veralgemeenbaarheid van uitkomste wat verkry is met betrekking tot instellings, vak, intervensie, resultate en koste was vir hierdie kohort aanvaarbaar. Aspekte van kennisvertaling (KV) soos diffusie (bewustheid van die VT-konsep) en verspreiding (publikasie en konferensie aanbiedings van die verskillende navorsingsstudies) is vervul. Gevolgtrekkings: Hierdie stapsgewyse navorsingsbenadering het die afwesigheid van die implementeringsaspek van kennis vertaling (KV) beklemtoon, naamlik die toepassing van die VT- of PVT-konsep by die kliniese praktyk. Die implikasie hiervan op die potensiaal om die pasiënt se behandelingskoste, bevrediging en mondgesondheidsverwante lewenskwaliteit binne die SA konteks positief te beïnvloed, is opmerklik. Die bewyse wat verkry en aangebied word, rig die huidige nie-bewysgebaseerde aspekte van prostodontiese leerplanne soos rehabilitasie om boogstatus by die grootste tandheelkundige onderwysinrigting in Afrika te voltooi. Daarbenewens is die doeltreffendheid van die stelsel gebaseer op ingeligte gesondheidsorgbeleid, wat die behoefte aan bewysgebaseerde navorsing beklemtoon, sowel op institusionele as privaatpraktyk vlak. Daarbenewens het die kontekstuele bewyse wat afgelei is van die navorsing wat na die huidige verhandeling (PhD) gedoen is, belangrike sleutelgebiede uitgelig in die belangrike menseregte-, akademiese en ekonomiese domein.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/102799
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