Salud Oral Integral: Tratamiento y Rehabilitación Oral en Personas Adultas y Personas Mayores con Edentulismo Parcial o Total
Problema de Salud AUGE N°47
juicio del panel y evidencia
En personas con edentulismo parcial unilateral, el Ministerio de Salud RECOMIENDA NO rehabilitar por medio de prótesis unilateral.
Comentarios del Panel de Expertos:
► Las recomendaciones fuertes basadas en certeza baja respecto de los efectos, son excepcionales. Sin embargo, la prótesis unilateral puede conllevar a riesgo vital o complicaciones de salud por aspiración o deglución del aparato protésico, y el panel considera que no proporciona beneficios clínicamente relevantes adicionales a los que entrega la prótesis con extensión contralateral.
El panel de expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente, cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación, se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Triviales | Pequeños | Moderados | Grandes | Varía | No lo sé |
|---|
Pequeños: El panel de expertos de la Guía estimó que los efectos deseables de «rehabilitar por medio de prótesis unilateral» en comparación a «rehabilitar con protesis con extensión contralateral» son pequeños. Considerando experiencia clínica del panel, las prótesis unilateral podría ser más cómoda, facilitar el manejo, es menos invasiva y puediese afectar menos la estética en algunos pacientes.
El tratamiento puediera requerir menos sesiones clínicas.
Evidencia de investigación
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Rehabilitar por medio de prótesis unilateral comparado con rehabilitar con prótesis con extensión contralateral para edentulismo parcial unilateral. |
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Pacientes |
Personas con edentulismo parcial unilateral. |
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Intervención |
Rehabilitar por medio de prótesis unilateral. |
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Comparación |
Rehabilitar con prótesis con extensión contralateral. |
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Desenlaces |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
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Efectividad |
No se identificaron estudios que comparen la efectividad de las intervenciones. |
— |
— |
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Efectos adversos |
Si bien no existen estudios comparativos, un estudio reportó 64 prótesis dentales removibles unilaterales deglutidas e impactadas en el esófago. De ellas, 17 prótesis reemplazaban un solo diente, 32 a dos dientes, 5 a tres dientes y 8 a cuatro dientes. La mortalidad ocurrió en 3 casos (4,68%) como resultado de hemorragia masiva, fuga esofágica, empiema, peritonitis y septicemia. Debido a la mayor retención, soporte y estabilidad de la prótesis con extensión contralateral, este efecto adverso no debiera ocurrir. |
⊕⊕◯◯1,2,3 Baja |
Rehabilitar por medio de prótesis unilateral probablemente aumenta el riesgo de deglución de la prótesis. |
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GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
1 Diseño observacional.
2 Se aumentó un nivel de certeza de evidencia por efecto grande, ya que si bien, corresponde a estudios de series de casos, este efecto adverso no debiera ocurrir en el otro tipo de prótesis por lo que la diferencia es grande.
3 Se disminuyó un nivel de certeza de evidencia por ser indirecta, ya que el estudio realiza un análisis retrospectivo de casos de prótesis unilaterales deglutidas y no se realiza una comparación entre el riesgo de deglución de prótesis con extensión lateral. Además, las prótesis incluidas en el estudio no cumplen con los estándares de calidad de las prótesis dentales removibles realizadas en Chile.
Fecha de elaboración de la tabla: Enero, 2019.
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2. De Kok IJ, Cooper LF, Guckes AD, McGraw K, Wright RF, Barrero CJ, Bak SY, Stoner LO. Factors Influencing Removable Partial Denture Patient-Reported Outcomes of Quality of Life and Satisfaction: A Systematic Review. Journal of prosthodontics : official journal of the American College of Prosthodontists. 2017;26(1):5-18.
3. Elliot Abt, Alan B Carr, Helen V Worthington. Interventions for replacing missing teeth: partially absent dentition. Cochrane Database of Systematic Reviews. 2012;2(2):CD003814.
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5. Khan S, Musekiwa A, Chikte UM, Omar R. Differences in functional outcomes for adult patients with prosthodontically-treated and -untreated shortened dental arches: a systematic review. PloS one. 2014;9(7):e101143.
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
3.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grandes | Moderados | Pequeños | Triviales | Varía | No lo sé |
|---|
Grandes: El panel de expertos de la Guía estimó que los efectos indeseables de «rehabilitar por medio de prótesis unilateral» en comparación a «rehabilitar con protesis con extensión contralateral» son grandes.
Según la evidencia y conocimiento clínica del panel, las prótesis unilaterales tiene mayores probabilidades de ser deglutidas o aspiradas, lo que podría implicar serias complicaciones del paciente, incluso la muerte, dado que pueden obstruir o perforar vías respiratorias o gastrointestinales. Por un lado, cuando las prótesis unilateral no llevan topes verticales (retenedores y apoyos), puede haber daño peridontal dado que se va incrustando en los tejidos blandos. Además son más inestable que las prótesis con extensión contralateral.
Evidencia de investigación
|
Rehabilitar por medio de prótesis unilateral comparado con rehabilitar con prótesis con extensión contralateral para edentulismo parcial unilateral. |
|
|||
|
Pacientes |
Personas con edentulismo parcial unilateral. |
|
||
|
Intervención |
Rehabilitar por medio de prótesis unilateral. |
|
||
|
Comparación |
Rehabilitar con prótesis con extensión contralateral. |
|
||
|
Desenlaces |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Efectividad |
No se identificaron estudios que comparen la efectividad de las intervenciones. |
— |
— |
|
|
Efectos adversos |
Si bien no existen estudios comparativos, un estudio reportó 64 prótesis dentales removibles unilaterales deglutidas e impactadas en el esófago. De ellas, 17 prótesis reemplazaban un solo diente, 32 a dos dientes, 5 a tres dientes y 8 a cuatro dientes. La mortalidad ocurrió en 3 casos (4,68%) como resultado de hemorragia masiva, fuga esofágica, empiema, peritonitis y septicemia. Debido a la mayor retención, soporte y estabilidad de la prótesis con extensión contralateral, este efecto adverso no debiera ocurrir. |
⊕⊕◯◯1,2,3 Baja |
Rehabilitar por medio de prótesis unilateral probablemente aumenta el riesgo de deglución de la prótesis. |
|
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
1 Diseño observacional.
2 Se aumentó un nivel de certeza de evidencia por efecto grande, ya que si bien, corresponde a estudios de series de casos, este efecto adverso no debiera ocurrir en el otro tipo de prótesis por lo que la diferencia es grande.
3 Se disminuyó un nivel de certeza de evidencia por ser indirecta, ya que el estudio realiza un análisis retrospectivo de casos de prótesis unilaterales deglutidas y no se realiza una comparación entre el riesgo de deglución de prótesis con extensión lateral. Además, las prótesis incluidas en el estudio no cumplen con los estándares de calidad de las prótesis dentales removibles realizadas en Chile.
Fecha de elaboración de la tabla: Enero, 2019.
Referencias
1. Ali Z, Baker SR, Shahrbaf S, Martin N, Vettore MV. Oral health-related quality of life after prosthodontic treatment for patients with partial edentulism: A systematic review and meta-analysis. The Journal of prosthetic dentistry. 2018;
2. De Kok IJ, Cooper LF, Guckes AD, McGraw K, Wright RF, Barrero CJ, Bak SY, Stoner LO. Factors Influencing Removable Partial Denture Patient-Reported Outcomes of Quality of Life and Satisfaction: A Systematic Review. Journal of prosthodontics : official journal of the American College of Prosthodontists. 2017;26(1):5-18.
3. Elliot Abt, Alan B Carr, Helen V Worthington. Interventions for replacing missing teeth: partially absent dentition. Cochrane Database of Systematic Reviews. 2012;2(2):CD003814.
4. Fueki, Kenji, Yoshida, Eiko, Igarashi, Yoshimasa. A systematic review of prosthetic restoration in patients with shortened dental arches. Japanese Dental Science Review. 2011;47(2):167-174.
5. Khan S, Musekiwa A, Chikte UM, Omar R. Differences in functional outcomes for adult patients with prosthodontically-treated and -untreated shortened dental arches: a systematic review. PloS one. 2014;9(7):e101143.
6. Liang S, Zhang Q, Witter DJ, Wang Y, Creugers NH. Effects of removable dental prostheses on masticatory performance of subjects with shortened dental arches: A systematic review. Journal of dentistry. 2015;43(10):1185-94.
7. Moldovan O, Rudolph H, Luthardt RG. Biological complications of removable dental prostheses in the moderately reduced dentition: a systematic literature review. Clinical oral investigations. 2018;22(7):2439-2461.
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62. Jemt T, Hedegård B, Wickberg K. Chewing patterns before and after treatment with completè maxillary and bilateral distal-extension mandibular removable partial dentures. The Journal of prosthetic dentistry. 1983;50(4):566-9.
63. Kapur KK. Veterans Administration Cooperative Dental Implant Study–comparisons between fixed partial dentures supported by blade-vent implants and removable partial dentures. Part II: Comparisons of success rates and periodontal health between two treatment modalities. The Journal of prosthetic dentistry. 1989;62(6):685-703.
64. Koyama S, Sasaki K, Yokoyama M, Sasaki T, Hanawa S. Evaluation of factors affecting the continuing use and patient satisfaction with Removable Partial Dentures over 5 years. Journal of prosthodontic research. 2010;54(2):97-101.
65. Kuboki T, Okamoto S, Suzuki H, Kanyama M, Arakawa H, Sonoyama W, Yamashita A. Quality of life assessment of bone-anchored fixed partial denture patients with unilateral mandibular distal-extension edentulism. The Journal of prosthetic dentistry. 1999;82(2):182-7.
66. Lassila V, Holmlund I, Koivumaa KK. Bite force and its correlations in different denture types. Acta odontologica Scandinavica. 1985;43(3):127-32.
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68. Liedberg B, Stoltze K, Owall B. The masticatory handicap of wearing removable dentures in elderly men. Gerodontology. 2005;22(1):10-6.
69. Montero J, Bravo M, López-Valverde A. Development of a specific indicator of the well-being of wearers of removable dentures. Community dentistry and oral epidemiology. 2011;39(6):515-24.
70. Montero J, Castillo-Oyagüe R, Lynch CD, Albaladejo A, Castaño A. Self-perceived changes in oral health-related quality of life after receiving different types of conventional prosthetic treatments: a cohort follow-up study. Journal of dentistry. 2013;41(6):493-503.
71. Müller S, Eickholz P, Reitmeir P, Eger T. Long-term tooth loss in periodontally compromised but treated patients according to the type of prosthodontic treatment. A retrospective study. Journal of oral rehabilitation. 2013;40(5):358-67.
72. Peršić S, Čelebić A. Influence of different prosthodontic rehabilitation options on oral health-related quality of life, orofacial esthetics and chewing function based on patient-reported outcomes. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2015;24(4):919-26.
73. Piwowarczyk A, Köhler KC, Bender R, Büchler A, Lauer HC, Ottl P. Prognosis for abutment teeth of removable dentures: a retrospective study. Journal of prosthodontics : official journal of the American College of Prosthodontists. 2007;16(5):377-82.
74. Rehmann P, Orbach K, Ferger P, Wöstmann B. Treatment outcomes with removable partial dentures: a retrospective analysis. The International journal of prosthodontics. 2013;26(2):147-50.
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78. Shoi K, Fueki K, Usui N, Taira M, Wakabayashi N. Influence of posterior dental arch length on brain activity during chewing in patients with mandibular distal extension removable partial dentures. Journal of oral rehabilitation. 2014;41(7):486-95.
79. Shugars DA, Bader JD, White BA, Scurria MS, Hayden WJ, Garcia RI. Survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. Journal of the American Dental Association (1939). 1998;129(8):1089-95.
80. Stober T, Bermejo JL, Beck-Mussoter J, Seche AC, Lehmann F, Koob J, Rammelsberg P. Clinical performance of conical and electroplated telescopic double crown-retained partial dentures: a randomized clinical study. The International journal of prosthodontics. 2012;25(3):209-16.
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82. Szentpétery AG, John MT, Slade GD, Setz JM. Problems reported by patients before and after prosthodontic treatment. The International journal of prosthodontics. 2005;18(2):124-31.
83. Tada S, Ikebe K, Matsuda K, Maeda Y. Multifactorial risk assessment for survival of abutments of removable partial dentures based on practice-based longitudinal study. Journal of dentistry. 2013;41(12):1175-80.
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de «rehabilitar por medio de prótesis unilateral» en comparación a «rehabilitar con protesis con extensión contralateral». La certeza general de la evidencia se establece en función del único desenlace reportado: efectos adversos.
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia (GRADE) |
|
|
Efectividad |
|
Desenlace no reportado en la evidencia |
|
|
Efectos adversos |
Crítico |
⊕⊕◯◯1,2,3 Baja |
|
1 Diseño observacional.
2 Se aumentó un nivel de certeza de evidencia por efecto grande, ya que si bien, corresponde a estudios de series de casos, este efecto adverso no debiera ocurrir en el otro tipo de prótesis por lo que la diferencia es grande.
3 Se disminuyó un nivel de certeza de evidencia por ser indirecta, ya que el estudio realiza un análisis retrospectivo de casos de prótesis unilaterales deglutidas y no se realiza una comparación entre el riesgo de deglución de prótesis con extensión lateral. Además, las prótesis incluidas en el estudio no cumplen con los estándares de calidad de las prótesis dentales removibles realizadas en Chile.
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Probablemente no hay incertidumbre ni variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el panel de expertos de la Guía consideró que probablemente no hay incertidumbre ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «rehabilitar por medio de prótesis unilateral» y «rehabilitar con protesis con extensión contralateral». La mayoría de los pacientes informados optaría por prótesis con extensión contralateral dado su seguridad, sin embargo podría haber algunos pacientes que priorizarían lo estético o facilidad de manejo de la protesis unilateral.
Evidencia de investigación
No se encuentra evidencia que compare rehabilitar por medio de prótesis unilateral en comparación con rehabilitar con prótesis con extensión contralateral en personas con edentulismo parcial.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de las preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Favorece la comparación: Considerando que la intervención es «rehabilitar por medio de prótesis unilateral» y la comparación es «rehabilitar con protesis con extensión contralateral», el panel de expertos de la Guía opinó que el balance entre efectos deseables e indeseables claramente favorece «rehabilitar con protesis con extensión contralateral». Lo anterior, considerando que, a pesar de que existe baja certeza de la evidencia general, la evidencia reporta 3 casos de muerte (4,68%) asociada al uso de prótesis parcial unilateral como resultado de hemorragia masiva, fuga esofágica, empiema, peritonitis y septicemia, mientras que la mayor retención, soporte y estabilidad de la prótesis con extensión contralateral, este efecto adverso no debiera ocurrir.
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos y ahorros despreciables: El panel de expertos de la Guía consideró que los costos y ahorros de «rehabilitar por medio de prótesis unilateral» son despreciables si se compara con «rehabilitar con protesis con extensión contralateral», el panel indica que los costos de realizar una u otra intervención son similares, aunque la prótesis unilateral pudiese ser más barata y requierir de un menor número de sesiones de instalación.
Evidencia de investigación
Se presentó una tabla de costos referenciales al panel, pero este estimó que no eran costos representativos, por lo que la desestimó como antecedente.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda de costos referenciales de las intervenciones
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Ningún estudio incluido: No se realizó la búsqueda de evidencia que abordaran la costo-efectividad ya que las intervenciones evaluadas no es considerado de alto costo, según el Decreto 80 «Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850».
1. Anual $2.418.399 y Mensual $201.533. Ministerio de Salud. Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850 [Internet]. Santiago; 2015 Nov.
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente ningún impacto: El panel de expertos de la Guía consideró que probablemente no tendría ningún impacto en la equidad en salud si se recomendase «rehabilitar por medio de prótesis unilateral».
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente no: El panel de expertos de la Guía consideró que «rehabilitar por medio de prótesis unilateral» probablemente NO es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros). Probablemente en profesionales clínicos y pacientes podría haber cierta variabilidad en términos de aceptar la prótesis unilateral, mentras que pagadores y directivos no la aceptarían por sus antecedentes.
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El panel de expertos de la Guía consideró que «rehabilitar por medio de prótesis unilateral» probablemente SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.