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 total inferior, el Ministerio de Salud SUGIERE rehabilitar por medio de prótesis fija sobre implante o rehabilitar por medio de sobredentadura implanto asistida (o implantosoportada).
Comentarios del Panel de Expertos:
► La rehabilitación con prótesis fija sobre implante requiere mayor entrenamiento técnico e implica mayor costo.
► En personas con dificultad para realizar una adecuada higiene bucal, la sobredentadura implanto asistida podría ser más adecuada (menor dificultad para realizar la higiene y mantenimiento por parte del cuidador o de la misma persona).
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 fija sobre implante» en comparación a «rehabilitar por medio de sobredentadura implanto asistida» son pequeños considerando la evidencia, sin embargo, a experiencia del panel, la evidencia presentada subestima la satisfacción de los pacientes y la calidad de vida respecto a la prótesis fija sobreimplante versus la prótesis implantosoportada. Es relevante considerar que la protesis fija podría producir menos reabsorción.
Evidencia de investigación
|
Rehabilitar por medio de prótesis fija sobre implante para edentulismo total inferior. |
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|
Pacientes |
Personas con edentulismo total inferior. |
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|
Intervención |
Rehabilitar por medio de prótesis fija sobre implante. |
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|
Comparación |
Rehabilitar por medio de sobredentadura implanto asistida o implantosoportada |
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|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
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|
Sobredentadura implanto asistida |
Prótesis fija sobre implantes |
Diferencia (IC 95%) |
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|
Calidad de vida relacionada con la salud oral** |
— 1 ensayo / 20 pacientes [9] |
89,8 puntos menos |
80,2 puntos menos |
DM: |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría empeorar la calidad de vida en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Nivel de satisfacción del paciente*** |
— 1 ensayo / 20 pacientes [9] |
64,4 puntos |
58,3 puntos |
DM: 6,1 menos (19,25 menos a 7,05 más) |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría disminuir el nivel de satisfacción en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Necesidad de rebasado de prótesis antagonista |
RR 0,71 (0,41 a 1,22) 2 ensayos / 68 pacientes [9,27]. |
514 por 1000 |
365 por 1000 |
Diferencia: (303 menos a 113 más) |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría disminuir la necesidad de rebasado de la prótesis antagonista en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Complicaciones protésicas |
— 2 ensayos / 68 pacientes [9,27]. |
Un estudio [9] reportó 25 eventos de desajuste protésico en el grupo intervención versus 30 eventos en el grupo control a los 12 meses de seguimiento.
En otro estudio [27], en 5 y 17 casos tuvieron que rehacerse las prótesis en el grupo intervención y control respectivamente a los 4 años de seguimiento. |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría tener poco impacto en la incidencia de complicaciones protésicas en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
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GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
DM: diferencia de media// RR: Riesgo relativo // IC 95%: Intervalo de confianza del 95%
**La calidad de vida relacionada con la salud oral fue medida el uso de la versión de 49 elementos del Perfil de impacto en la salud oral (OHIP-49). Este cuestionario consta de 49 ítems que cubren siete dominios: limitación funcional, dolor físico, malestar psicológico, discapacidad física, discapacidad psicológica, discapacidad social y discapacidad. Estos ítems son puntuados de 0 a 4, desde nunca (0) a muy a menudo (4).
***Las opiniones de los pacientes sobre sus prótesis actuales en términos de satisfacción general, retención y estabilidad, masticación, higiene bucal, comodidad, habla y estética se evaluaron mediante una escala visual análoga (VAS-14). Cada escala usó una línea de 100 mm con «completa insatisfacción» en un extremo de la línea y «completa satisfacción» en el otro.
1 Se disminuyó un nivel de certeza por riesgo de sesgo, ya que ambos ensayos presentan problemas en la asignación de la secuencia aleatoria y el ocultamiento de esta.
2 Se disminuyó dos niveles de certeza de evidencia por imprecisión, ya que cada extremo del intervalo de confianza conlleva a decisiones opuestas, o en los casos en que no se cuenta con un intervalo, se trata de estudios con baja cantidad de pacientes.
Fecha de elaboración de la tabla: Enero, 2019.
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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 |
|---|
Pequeños: El panel de expertos de la Guía estimó que los efectos indeseables de «rehabilitar por medio de prótesis fija sobre implante» en comparación a «rehabilitar por medio de sobredentadura implanto asistida» son pequeños, considerando la evidencia y experiencia clínica del panel. La prótesis fija puede implicar mayores dificultades técnicas en su realización, mayor cuidado de higiene y no cubre toda la zona desdentada, produciendo incomodidad, requiere involucrar más tiempo en el cuidado de la higiene y habilidad motriz.
Evidencia de investigación
|
Rehabilitar por medio de prótesis fija sobre implante para edentulismo total inferior. |
||||||
|
Pacientes |
Personas con edentulismo total inferior. |
|||||
|
Intervención |
Rehabilitar por medio de prótesis fija sobre implante. |
|||||
|
Comparación |
Rehabilitar por medio de sobredentadura implanto asistida o implantosoportada |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
Sobredentadura implanto asistida |
Prótesis fija sobre implantes |
Diferencia (IC 95%) |
||||
|
Calidad de vida relacionada con la salud oral** |
— 1 ensayo / 20 pacientes [9] |
89,8 puntos menos |
80,2 puntos menos |
DM: |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría empeorar la calidad de vida en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Nivel de satisfacción del paciente*** |
— 1 ensayo / 20 pacientes [9] |
64,4 puntos |
58,3 puntos |
DM: 6,1 menos (19,25 menos a 7,05 más) |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría disminuir el nivel de satisfacción en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Necesidad de rebasado de prótesis antagonista |
RR 0,71 (0,41 a 1,22) 2 ensayos / 68 pacientes [9,27]. |
514 por 1000 |
365 por 1000 |
Diferencia: (303 menos a 113 más) |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría disminuir la necesidad de rebasado de la prótesis antagonista en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
|
Complicaciones protésicas |
— 2 ensayos / 68 pacientes [9,27]. |
Un estudio [9] reportó 25 eventos de desajuste protésico en el grupo intervención versus 30 eventos en el grupo control a los 12 meses de seguimiento.
En otro estudio [27], en 5 y 17 casos tuvieron que rehacerse las prótesis en el grupo intervención y control respectivamente a los 4 años de seguimiento. |
⊕◯◯◯1,2 Muy baja |
Rehabilitar con prótesis fija sobre implante podría tener poco impacto en la incidencia de complicaciones protésicas en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. |
||
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
DM: diferencia de media// RR: Riesgo relativo // IC 95%: Intervalo de confianza del 95%
**La calidad de vida relacionada con la salud oral fue medida el uso de la versión de 49 elementos del Perfil de impacto en la salud oral (OHIP-49). Este cuestionario consta de 49 ítems que cubren siete dominios: limitación funcional, dolor físico, malestar psicológico, discapacidad física, discapacidad psicológica, discapacidad social y discapacidad. Estos ítems son puntuados de 0 a 4, desde nunca (0) a muy a menudo (4).
***Las opiniones de los pacientes sobre sus prótesis actuales en términos de satisfacción general, retención y estabilidad, masticación, higiene bucal, comodidad, habla y estética se evaluaron mediante una escala visual análoga (VAS-14). Cada escala usó una línea de 100 mm con «completa insatisfacción» en un extremo de la línea y «completa satisfacción» en el otro.
1 Se disminuyó un nivel de certeza por riesgo de sesgo, ya que ambos ensayos presentan problemas en la asignación de la secuencia aleatoria y el ocultamiento de esta.
2 Se disminuyó dos niveles de certeza de evidencia por imprecisión, ya que cada extremo del intervalo de confianza conlleva a decisiones opuestas, o en los casos en que no se cuenta con un intervalo, se trata de estudios con baja cantidad de pacientes.
Fecha de elaboración de la tabla: Enero, 2019.
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143. Garrett NR, Kapur KK, Hamada MO, Roumanas ED, Freymiller E, Han T, Diener RM, Levin S, Chen T. A randomized clinical trial comparing the efficacy of mandibular implant-supported overdentures and conventional dentures in diabetic patients. Part II. Comparisons of masticatory performance. The Journal of prosthetic dentistry. 1998;79(6):632-40.
144. Beikler T, Flemmig TF. EAO consensus conference: economic evaluation of implant-supported prostheses. Clinical oral implants research. 2015;26 Suppl 11:57-63.
145. Geertman ME, Slagter AP, van Waas MA, Kalk W. Comminution of food with mandibular implant-retained overdentures. Journal of dental research. 1994;73(12):1858-64.
146. Hoogstraten J, Lamers LM. Patient satisfaction after insertion of an osseointegrated implant bridge. Journal of oral rehabilitation. 1987;14(5):481-7.
147. Slot W, Raghoebar GM, Vissink A, Meijer HJ. A comparison between 4 and 6 implants in the maxillary posterior region to support an overdenture; 1-year results from a randomized controlled trial. Clinical oral implants research. 2014;25(5):560-6.
148. Krennmair G., Seemann R., Weinlander M. & Piehslinger E.. Comparison of ball and telescopic crown attachments in implant‐retained mandibular overdentures: a 5‐year prospective study. The International Journal of Oral and Maxillofacial Implants. 2011;26:598-606.
149. Kordatzis K, Wright PS, Meijer HJ. Posterior mandibular residual ridge resorption in patients with conventional dentures and implant overdentures. The International journal of oral & maxillofacial implants. 2003;18(3):447-52.
150. Heydecke G, Boudrias P, Awad MA, De Albuquerque RF, Lund JP, Feine JS. Within-subject comparisons of maxillary fixed and removable implant prostheses: Patient satisfaction and choice of prosthesis. Clinical oral implants research. 2003;14(1):125-30.
151. Jacobs R, Schotte A, van Steenberghe D, Quirynen M, Naert I. Posterior jaw bone resorption in osseointegrated implant-supported overdentures. Clinical oral implants research. 1992;3(2):63-70.
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155. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants in posterior partially edentulous patients. The International journal of prosthodontics. 1993;6(2):189-96.
156. Fontijn-Tekamp FA, Slagter AP, Van Der Bilt A, Van ‘T Hof MA, Witter DJ, Kalk W, Jansen JA. Biting and chewing in overdentures, full dentures, and natural dentitions. Journal of dental research. 2000;79(7):1519-24.
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161. Hellem S, Karlsson U, Almfeldt I, Brunell G, Hamp SE, Astrand P. Nonsubmerged implants in the treatment of the edentulous lower jaw: a 5-year prospective longitudinal study of ITI hollow screws. Clinical implant dentistry and related research. 2001;3(1):20-9.
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164. Eliasson A, Palmqvist S, Svenson B, Sondell K. Five-year results with fixed complete-arch mandibular prostheses supported by 4 implants. The International journal of oral & maxillofacial implants. 2000;15(4):505-10.
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166. Romeo E, Lops D, Margutti E, Ghisolfi M, Chiapasco M, Vogel G. Long-term survival and success of oral implants in the treatment of full and partial arches: a 7-year prospective study with the ITI dental implant system. The International journal of oral & maxillofacial implants. 2004;19(2):247-59.
167. Burns DR, Unger JW, Elswick RK, Giglio JA. Prospective clinical evaluation of mandibular implant overdentures: Part II–Patient satisfaction and preference. The Journal of prosthetic dentistry. 1995;73(4):364-9.
168. Stoker GT, Wismeijer D, van Waas MA. An eight-year follow-up to a randomized clinical trial of aftercare and cost-analysis with three types of mandibular implant-retained overdentures. Journal of dental research. 2007;86(3):276-80.
169. Crespi R, Vinci R, Capparé P, Romanos GE, Gherlone E. A clinical study of edentulous patients rehabilitated according to the «all on four» immediate function protocol. The International journal of oral & maxillofacial implants. 2012;27(2):428-34.
170. Ekelund JA, Lindquist LW, Carlsson GE, Jemt T. Implant treatment in the edentulous mandible: a prospective study on Brånemark system implants over more than 20 years. The International journal of prosthodontics. 2004;16(6):602-8.
171. De Bruyn H, Collaert B, Lindén U, Johansson C, Albrektsson T. Clinical outcome of Screw Vent implants. A 7-year prospective follow-up study. Clinical oral implants research. 1999;10(2):139-48.
172. Allen F, McMillan A. Food selection and perceptions of chewing ability following provision of implant and conventional prostheses in complete denture wearers. Clinical oral implants research. 2002;13(3):320-6.
173. Preciado A, Del Río J, Lynch CD, Castillo-Oyagüe R. A new, short, specific questionnaire (QoLIP-10) for evaluating the oral health-related quality of life of implant-retained overdenture and hybrid prosthesis wearers. Journal of dentistry. 2013;41(9):753-63.
174. Friberg B, Nilson H, Olsson M, Palmquist C. Mk II: the self-tapping Brånemark implant: 5-year results of a prospective 3-center study. Clinical oral implants research. 1997;8(4):279-85.
175. Andersson B, Odman P, Lindvall AM, Brånemark PI. Five-year prospective study of prosthodontic and surgical single-tooth implant treatment in general practices and at a specialist clinic. The International journal of prosthodontics. 1998;11(4):351-5.
176. Grogono AL, Lancaster DM, Finger IM. Dental implants: a survey of patients’ attitudes. The Journal of prosthetic dentistry. 1989;62(5):573-6.
177. Ericsson I, Randow K, Nilner K, Peterson A. Early functional loading of Brånemark dental implants: 5-year clinical follow-up study. Clinical implant dentistry and related research. 2000;2(2):70-7.
178. Kimoto K, Garrett NR. Effect of mandibular ridge height on masticatory performance with mandibular conventional and implant-assisted overdentures. The International journal of oral & maxillofacial implants. 2003;18(4):523-30.
179. Nyström E, Nilson H, Gunne J, Lundgren S. A 9-14 year follow-up of onlay bone grafting in the atrophic maxilla. International journal of oral and maxillofacial surgery. 2009;38(2):111-6.
180. Weinländer M, Piehslinger E, Krennmair G. Removable implant-prosthodontic rehabilitation of the edentulous mandible: five-year results of different prosthetic anchorage concepts. The International journal of oral & maxillofacial implants. 2010;25(3):589-97.
181. Ferrigno N, Laureti M, Fanali S, Grippaudo G. A long-term follow-up study of non-submerged ITI implants in the treatment of totally edentulous jaws. Part I: Ten-year life table analysis of a prospective multicenter study with 1286 implants. Clinical oral implants research. 2002;13(3):260-73.
182. Becker W, Dahlin C, Lekholm U, Bergstrom C, van Steenberghe D, Higuchi K, Becker BE. Five-year evaluation of implants placed at extraction and with dehiscences and fenestration defects augmented with ePTFE membranes: results from a prospective multicenter study. Clinical implant dentistry and related research. 1999;1(1):27-32.
183. Listl S, Fischer L, Giannakopoulos NN. An economic evaluation of maxillary implant overdentures based on six vs. four implants. BMC oral health. 2014;14:105.
184. Degidi M., Nardi D. & Piattelli A.. Immediate loading of the edentulous maxilla with a definitive restoration supported by an intraorally welded titanium bar and tilted implants. The International Journal of Oral and Maxillofacial Implants. 2010;25:1175-1182.
185. Malmstrom H, Xiao J, Romanos G, Ren YF. Two-Year Success Rate of Implant-Retained Mandibular Overdentures by Novice General Dentistry Residents. The Journal of oral implantology. 2015;41(3):268-75.
186. Akca K., Cehreli M.C. & Uysal S.. Marginal bone loss and prosthetic maintenance of bar‐retained implant‐supported overdentures: a prospective study. The International Journal of Oral and Maxillofacial Implants. 2010;25:137-145.
187. Behneke A, Behneke N, d’Hoedt B. A 5-year longitudinal study of the clinical effectiveness of ITI solid-screw implants in the treatment of mandibular edentulism. The International journal of oral & maxillofacial implants. 2002;17(6):799-810.
188. Martínez-González JM, Martín-Ares M, Cortés-Bretón Brinkmann J, Calvo-Guirado JL, Barona-Dorado C. Impact of prosthetic rehabilitation type on satisfaction of completely edentulous patients. A 5-year prospective study. Acta odontologica Scandinavica. 2013;71(5):1303-8.
189. Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, McKenna S, McNamara DC, van Steenberghe D, Taylor R, Watson RM, Herrmann I. A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. The International journal of oral & maxillofacial implants. 1996;11(3):291-8.
190. Haraldson T, Carlsson GE. Bite force and oral function in patients with osseointegrated oral implants. Scandinavian journal of dental research. 1977;85(3):200-8.
191. van Kampen FM, van der Bilt A, Cune MS, Fontijn-Tekamp FA, Bosman F. Masticatory function with implant-supported overdentures. Journal of dental research. 2004;83(9):708-11.
192. Khoo HD, Chai J, Chow TW. Prosthetic outcome, patient complaints, and nutritional effects on elderly patients with magnet-retained, implant-supported overdentures–a 1-year report. The International journal of oral & maxillofacial implants. 2013;28(5):1278-85.
193. Boerrigter EM, Stegenga B, Raghoebar GM, Boering G. Patient satisfaction and chewing ability with implant-retained mandibular overdentures: a comparison with new complete dentures with or without preprosthetic surgery. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 1995;53(10):1167-73.
194. Cune MS, de Putter C, Hoogstraten J. Treatment outcome with implant-retained overdentures: Part II–Patient satisfaction and predictability of subjective treatment outcome. The Journal of prosthetic dentistry. 1994;72(2):152-8.
195. Brennan M, Houston F, O’Sullivan M, O’Connell B. Patient satisfaction and oral health-related quality of life outcomes of implant overdentures and fixed complete dentures. The International journal of oral & maxillofacial implants. 2010;25(4):791-800.
196. Mendonca DB, Prado MM, Mendes FA, Borges Tde F, Mendonça G, do Prado CJ, Neves FD. Comparison of masticatory function between subjects with three types of dentition. The International journal of prosthodontics. 2009;22(4):399-404.
197. Bakke M, Holm B, Gotfredsen K. Masticatory function and patient satisfaction with implant-supported mandibular overdentures: a prospective 5-year study. The International journal of prosthodontics. 2002;15(6):575-81.
198. Jacobs R, van Steenberghe D, Nys M, Naert I. Maxillary bone resorption in patients with mandibular implant-supported overdentures or fixed prostheses. The Journal of prosthetic dentistry. 1993;70(2):135-40.
199. Büttel AE, Gratwohl DA, Sendi P, Marinello CP. Immediate loading of two unsplinted mandibular implants in edentulous patients with an implant-retained overdenture: an observational study over two years. Schweizer Monatsschrift fur Zahnmedizin = Revue mensuelle suisse d’odonto-stomatologie = Rivista mensile svizzera di odontologia e stomatologia. 2012;122(5):392-7.
200. Al-Zubeidi MI, Alsabeeha NH, Thomson WM, Payne AG. Patient satisfaction and dissatisfaction with mandibular two-implant overdentures using different attachment systems: 5-year outcomes. Clinical implant dentistry and related research. 2012;14(5):696-707.
201. MacEntee MI, Walton JN, Glick N. A clinical trial of patient satisfaction and prosthodontic needs with ball and bar attachments for implant-retained complete overdentures: three-year results. The Journal of prosthetic dentistry. 2005;93(1):28-37.
202. Liddelow G, Henry P. The immediately loaded single implant-retained mandibular overdenture: a 36-month prospective study. The International journal of prosthodontics. 2010;23(1):13-21.
203. Makkonen TA, Holmberg S, Niemi L, Olsson C, Tammisalo T, Peltola J. A 5-year prospective clinical study of Astra Tech dental implants supporting fixed bridges or overdentures in the edentulous mandible. Clinical oral implants research. 1997;8(6):469-75.
204. Rasmusson L, Roos J, Bystedt H. A 10-year follow-up study of titanium dioxide-blasted implants. Clinical implant dentistry and related research. 2005;7(1):36-42.
205. Harder S, Wolfart S, Egert C, Kern M. Three-year clinical outcome of single implant-retained mandibular overdentures–results of preliminary prospective study. Journal of dentistry. 2011;39(10):656-61.
206. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A. Mandibular overdentures supported by two or four endosseous implants: a 10-year clinical trial. Clinical oral implants research. 2009;20(7):722-8.
207. Lekholm U, Gunne J, Henry P, Higuchi K, Lindén U, Bergström C, van Steenberghe D. Survival of the Brånemark implant in partially edentulous jaws: a 10-year prospective multicenter study. The International journal of oral & maxillofacial implants. 1999;14(5):639-45.
208. Oh SH, Kim Y, Park JY, Jung YJ, Kim SK, Park SY. Comparison of fixed implant-supported prostheses, removable implant-supported prostheses, and complete dentures: patient satisfaction and oral health-related quality of life. Clinical oral implants research. 2016;27(2):e31-7.
209. Wright PS, Glantz PO, Randow K, Watson RM. The effects of fixed and removable implant-stabilised prostheses on posterior mandibular residual ridge resorption. Clinical oral implants research. 2002;13(2):169-74.
210. Zitzmann NU, Marinello CP, Sendi P. A cost-effectiveness analysis of implant overdentures. Journal of dental research. 2006;85(8):717-21.
211. Attard NJ, Zarb GA, Laporte A. Long-term treatment costs associated with implant-supported mandibular prostheses in edentulous patients. The International journal of prosthodontics. 2005;18(2):117-23.
212. Heydecke G, McFarland DH, Feine JS, Lund JP. Speech with maxillary implant prostheses: ratings of articulation. Journal of dental research. 2004;83(3):236-40.
213. de Grandmont P, Feine JS, Taché R, Boudrias P, Donohue WB, Tanguay R, Lund JP. Within-subject comparisons of implant-supported mandibular prostheses: psychometric evaluation. Journal of dental research. 1994;73(5):1096-104.
214. Raghoebar, Gerry M., Meijer, Henny J. A., Stegenga, Boudewijn, Van’t Hof, Martin A., Van Oort, Rob P., Vissink, Arjan. Effectiveness of three treatment modalities for the edentulous mandible. Clinical Oral Implants Research. 2000;11(3):195-201.
215. Ericsson I, Randow K, Nilner K, Petersson A. Some clinical and radiographical features of submerged and non-submerged titanium implants. A 5-year follow-up study. Clinical oral implants research. 1997;8(5):422-6.
216. Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic study of non-submerged dental implants. Clinical oral implants research. 2000;11(2):144-53.
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 |
|---|
Muy Baja: Existe considerable incertidumbre respecto del efecto de «rehabilitar por medio de prótesis fija sobre implante» en comparación a «rehabilitar por medio de sobredentadura implanto asistida». La certeza general de la evidencia se establece en función del desenlace o resultado en salud considerado como crítico para los pacientes, en este caso, calidad de vida.
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia (GRADE) |
|
Calidad de vida relacionada con la salud oral |
CRÍTICO |
⨁◯◯◯ |
|
Satisfacción del paciente |
IMPORTANTE |
⨁◯◯◯ |
|
Necesidad de rebasado de prótesis maxilar |
NO ES IMPORTANTE |
⨁◯◯◯ |
|
Complicaciones protésicas |
IMPORTANTE |
⨁◯◯◯ |
a. Se disminuyó un nivel de certeza por riesgo de sesgo, ya que ambos ensayos presentan problemas en la asignación de la secuencia aleatoria y el ocultamiento de esta.
b. Se disminuyó dos niveles de certeza de evidencia por imprecisión, ya que cada extremo del intervalo de confianza conlleva a decisiones opuestas, o en los casos en que no se cuenta con un intervalo, se trata de estudios con baja cantidad de pacientes.
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 o variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «rehabilitar por medio de prótesis fija sobre implante» y «rehabilitar por medio de sobredentadura implanto asistida». A pesar de la evidencia presentada, el panel considera que en Chile la mayoría de las personas escogerían la prótesis fija. Dentro de las personas que no escogerían esta alternativa, pordrían estar cuidadores de pacientes con dependencia moderada a severa, lo cuales podrían optar por la protesis implanto retenida dado que se ajusta mejor a las características/necesidades del paciente, ya que los cuidados de la higiene están a cargo de un cuidador.
Evidencia de investigación
Un estudio (1) evaluó la satisfacción de los pacientes con edentulismo total inferior respecto rehabilitar con prótesis fija en comparación con sobredentadura implanto asistida (o implantosoportada), de este se concluye que con prótesis fija sobre implante podría disminuir el nivel de satisfacción en comparación a rehabilitar con prótesis implantoasistida. Sin embargo, existe considerable incertidumbre dado que la certeza de la evidencia es muy baja. Las opiniones de los pacientes sobre sus prótesis se midieron en función de su satisfacción general, retención y estabilidad, masticación, higiene bucal, comodidad, habla y estética, se utilizó la escala visual análoga (VAS-14). Cada escala usó una línea de 100 mm con «completa insatisfacción» en un extremo de la línea y «completa satisfacción» en el otro, el grupo con sobredentadura implanto asistida obtuvo una media de 64,4 puntos, mientras que aquellos con prótesis fila tuvieron una media de 58,3 puntos.
En una búsqueda complementaria y específica de valores y preferencias de los pacientes, no se encontraron estudios relevantes.
Referencias
1. De Kok IJ, Chang K-H, Lu T-S, Cooper LF. Comparison of three-implant-supported fixed dentures and two-implant-retained overdentures in the edentulous mandible: a pilot study of treatment efficacy and patient satisfaction. Int J Oral Maxillofac Implants [Internet]. [cited 2019 Dec 19];26(2):415–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21483895
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 |
|---|
No favorece la intervención ni la comparación: Considerando que la intervención es «rehabilitar por medio de prótesis fija sobre implante» y la comparación es «rehabilitar por medio de sobredentadura implanto asistida», el panel de expertos de la Guía opinó que el balance entre efectos deseables e indeseables no favorece ninguna de las dos alternativas. Esto considerando de que existe certeza muy baja de la evidencia, que los efectos deseables e indeseables de la prótesis fija respecto a la sobredentadura implanto asistida son pequeños. A pesar de que el panel estima que la mayoría de los pacientes preferiría una prótesis fija, indica que en pacientes con dependencia moderada a severa la protesis implanto retenida podría ajustarse mejor a las características/necesidades del paciente, ya que los cuidados de la higiene están a cargo de un cuidador.
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 extensos: El panel de expertos de la Guía consideró que los costos de «rehabilitar por medio de prótesis fija sobre implante» son grandes si se compara con los costos de «rehabilitar por medio de sobredentadura implanto asistida», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
A continuación, se muestran los costos referenciales, es preciso considerar que estos costos fueron recogidos con el único objetivo de constituir un antecedente aproximado.
|
Desenlaces |
Importancia |
Certeza de la evidencia (GRADE) |
|
Calidad de vida relacionada con la salud oral |
CRÍTICO |
⨁◯◯◯ |
|
Satisfacción del paciente |
IMPORTANTE |
⨁◯◯◯ |
|
Necesidad de rebasado de prótesis maxilar |
NO ES IMPORTANTE |
⨁◯◯◯ |
|
Complicaciones protésicas |
IMPORTANTE |
⨁◯◯◯ |
** Esta ítem está compuesto por varias prestaciones sanitarias.
** El programa de prestaciones valoradas son paquetes de servicios o productos de salud entregados por hospitales públicos, los cuales son costeadas por FONASA contra producción. Solo algunos hospitales públicos adhieren a estos paquetes y su valor es un estimado estándar.
Referencias:
1. Precio obtenido de la base de datos del Programa de Prestaciones Valoradas. Este precio agrupa varias prestaciones.
2. Precio indicado por Clínica Privada (Integramédica, 2018).
Referencias
1. Precio obtenido de la base de datos del Programa de Prestaciones Valoradas. Este precio agrupa varias prestaciones.
2. Precio indicado por Clínica Privada (Integramédica, 2018).
2. Precio indicado por Clínica Privada (Integramédica, 2018).
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 |
|---|
Probablemente favorece la intervención: Considerando que la intervención es «rehabilitar por medio de prótesis fija sobre implante» y la comparación es «rehabilitar por medio de sobredentadura implanto asistida», el panel de expertos de la Guía opinó que probablemente la alternativa más costo-efectiva es «rehabilitar por medio de prótesis fija sobre implante». A pesar de existir evidencia respecto a la costo efectividad de la prótesis fija, esta cálculo proviene de otros contextos, lo que podría no ser del todo transferible a Chile.
Evidencia de investigación
Se hizo una revisión de evidencia y se encontraron algunos estudios que pudieran responder la pregunta, sin embargo, el panel desestimó la evidencia, indicando que son estudios que no son aplicable al contexto nacional dado que en Chile el precio de la intervención representa una proporción mayor respecto a los ingresos promedios de la población. Ver Informe de búsqueda y síntesis de evidencia de
costo-efectividad de las intervenciones.
Referencias
1. Zitzmann NU, Marinello CP, Sendi P. A cost-effectiveness analysis of implant overdentures. J Dent Res. 2006;85(8):717–21.
2. Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS, Thomason JM. Cost-effectiveness of Mandibular and Conventional Dentures and Conventional Dentures in the Edentulous Elderly. J Dent Res. 2005;84(9):794–9.
2. Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS, Thomason JM. Cost-effectiveness of Mandibular and Conventional Dentures and Conventional Dentures in the Edentulous Elderly. J Dent Res. 2005;84(9):794–9.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de costo efectividad de las intervenciones
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Reducida: El panel de expertos de la Guía consideró que la equidad en salud se reduciría si se recomendase «rehabilitar por medio de prótesis fija sobre implante», dado que no hay oferta en el sistema público, las personas con menores recursos tendrían mayores barreras para acceder a las prótesis fija.
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 fija sobre implante» probablemente NO es aceptable por algunas de las partes interesadas, dados los costos y la complejidad técnica.
11.- ¿Es factible implementar la intervención?
| 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 fija sobre implante» probablemente NO es factible implementar, contemplando que debe existir entrenamiento del profesional y equipamiento que no está implementado actualmente en el país.