(Dr. William Runyon co-authored this article.)

There is a growing challenge for our profession. The aging United States population now demands better alternatives to edentulism.

The problem with this challenge is that the key elements responsible for edentulism are not new to us. The numbers of older patients presenting with these key elements, however, is on the rise. The syndromes and diseases responsible are conditions we deal with daily. The problem arises when these common syndromes and diseases manifest themselves in destructive combinations.  Two or more of them occurring together seem to accelerate their lethal potential. The resulting mutilation and irreparable damage to our patients’ teeth is devastating. Yet we may become numb to the existence of these syndromes due to our familiarity with them. The problem and challenge I am referring to is terminal dentition.

A National Institute of Health study frames this impending challenge. The aging baby boomer population is responsible for much of this growing need. The studies show nearly 1 in 5 patients over the age of 60 are edentulous. That number jumps to 1 in 3 after the age of 75.1 The baby boom generation sees a new member turning 65 years of age every seven seconds. The number of edentate patients in the United States is currently stable at 9 million.2

The challenge for the restorative dentist is to identify these conditions affecting their patient's teeth to attempt to save them from terminal dentition. Once the assault from these corrosive syndromes begins, it is difficult to reverse the effects quickly and cost effectively.

The scope and magnitude of the diseases discussed in this article are not borderline caries cases. They are catastrophic and total in their scope of assault. We will discuss the psychological component of dealing with this diagnostic challenge in later articles, but first we must lay the groundwork of recognition. The following are some of the most common conditions and syndromes contributing to terminal dentition; xerostomia, rampant dental caries, GERD, severe periodontal disease, worn dentition and drug abuse.


​Also called dry mouth, xerostomia is a very common condition for many of our older patients. It is usually thought of in conjunction with Sjogren's syndrome, which is an autoimmune disorder. Xerostomia has a much broader clinical presentation potential. I see it most often as the result of poly-pharmacy. For the sake of this discussion, poly-pharmacy is defined as the taking of two or more prescription drugs. While we cannot discount the advantages medical advances have afforded each of us, it comes at a price. The dental complications associated with poly-pharmacy are undeniable. The devastating effects on decreased salivary flow are unmistakable. Lose the buffering effects of saliva and rampant decay is the result.

Rampant Dental Caries

Rampant dental caries is usually seen as a co-morbidity of xerostomia. When it affects the elderly, the root surfaces are the area most critically damaged. This is a common cause of terminal dentition.

Periodontal Disease

Severe periodontal disease is still ever present in our world today, affecting almost 1 in 4 Americans over the age of 65. This disease is responsible for edentulism in approximately 33 percent of this group.2 As a result, severe periodontal disease is a major contributor to terminal dentition.

Gastro Esophageal Reflux Disease

GERD may seem out of place on this list. It is, however, responsible for contributing to an acidic and resulting corrosive environment in the oral cavity. The damaging effects left behind are increasingly linked to root caries. Identified as a co-morbidity of sleep apnea, it is a condition that is seeing a rise in diagnoses. The effects of GERD leave behind signs dentists can readily identify. The resulting acid corrosion of the dentition is easily recognizable. The “Pot Hole” defect on occlusal surfaces of posterior teeth is one every dentist has seen. Additional signs include macroglossia, narrow mandible arch, high palatal vault, large uvula and enlarged tonsils.2

Worn Dentition

A worn dentition is responsible for terminal dentition in some of our patients as well. While it is rarely the sole contributor of terminal dentition, it is usually co-morbidity with xerostomia and GERD. Worn dentition is one of those subtle disease processes that can sneak up on you and your patient. Many times, you may wonder, “When do I say something about a patient's excessive wear?” I try and relate the consequences to worn dentition as soon as I see signs of wear.

Drug Abuse

Drug abuse is a slightly different contributor to terminal dentition. Many times, the patients with this disease process are much younger. Though it may seem unlikely that this group would be included in the terminal dentition conversation, their disease is no less damaging than those diseases outlined above. The rampant caries seen in this group is often times so advanced by the time they seek help, the damage is beyond repair. Many times, it is just too late to salvage their dentition. We need a restorative platform that addresses this impending need, and one resource is a familiar implant-supported restoration.

The Fixed Hybrid

Terminal dentition is one reason the FH is gaining new attention and popularity. The availability of immediate delivery is likely responsible for much of this new attention. Immediate delivery satisfies most patients facing the difficult dilemma of edentulism. You have no doubt heard advertisements for “Teeth in a day.” It comes as no surprise that a patient would be drawn to this type of resolution when faced with a denture. The comfort of knowing they will awaken from surgery with a fixed prosthesis is understandable.

You might now wonder if you need to advertise for this patient population. Should you blog for this particular group of patients or perhaps hire SEO advertisers to help you find them? I would tell you that you do not have to do any of the above to begin treating this patient population. Your desire to identify these patients merely involves identifying the syndrome we mentioned earlier.

In short, your next “new patient” examination might be an IMFH patient. It also may be a long-standing patient with new physiologic conditions that leave them vulnerable to disease. It may also be an emergency patient you are going to see next week. This last scenario is exactly how I met one of my IFH patients.

A Terminal Dentition Patient ...

I want to introduce you to Roger.

proarch patient figure 1
Smile close-up image.

Roger is a patient who came to my practice as an emergency patient. In Roger’s mind, he only needed his implant crown retightened.

proarch patient figure 2
Mandibular occlusal image.

During the oral examination, I recognized that Roger had three of the syndromes we discussed above. He exhibited extreme worn dentition, xerostomia and GERD. The result was profound. 

proarch patient figure 3
Retracted, teeth apart image.
proarch patient figure 4
Right lateral image.

The damage was extensive. It left his dentition in an extremely catastrophic state. My job at this point was to find a way to educate him as to the true state of his dentition. A patient does not always recognize the gravity of the situation until it is too late. It becomes our responsibility to inform them and educate them as to the consequences of these conditions. This is a great time to enlist the skills taught at Spear Education. The Facially Generated Treatment Planning course specifically equips a dentist to address these challenges. For example, knowing how to illustrate the patient’s true condition with 35 mm photography is a powerful teaching tool. It not only identifies the disease processes, but also effectively educates the patient as to their best restorative option.

When we see the syndromes causing a terminal dentition, we see the potential IMFH patient. I say potential patient because I believe that it is important for us to give these patients all their treatment options. Roger for example, was given several treatment plan options. Orthodontic correction and traditional crown and bridge were part of his treatment plan presentation. It was his choice as to which option best fit his life circumstance. Many times, I see patients drawn to the IFH because of its simplicity. Patients can see the end goal more easily. There are fewer steps and they are happy to avoid an edentulous period no matter how short. Not all patients have options like Roger. In some cases the options for patients are more limited. The IFH may be their only fixed restorative choice.

... Could Be Your Next Patient

In conclusion, when you started this article you may have been after a specific answer to the question of, “Who are these patients?” or, “What does an IFH patient look like?”  It is my hope that you now realize the IFH patient can be anyone and everyone impacted by one of the key syndromes I have outlined today.

Remember you may be seeing your next IFH patient when you step back and really assess your patient's overall condition. Stop and take some photos of the patient’s dentition. Be aware of hard and soft tissue changes. Is there new recurrent coronal decay? Is there active root caries and decreased salivary flow? When you recognize signs of teeth under attack and segments of the dentition are affected, it may be time to take a new direction. The population of patients affected by these syndromes is only growing larger. 

Recognize the key syndromes outlined above and you may be seeing the next IFH patient in your practice.


  1. Dye BA, Thorton-Evans G, Li X. Lafolla T. Dental Caries and Tooth Loss in Adults in the United States, 2011-2012: NCHS Data Brief. No 197, May 2015. U.S. Department Of Health And Human Services
  2. Int.J Dentistry. The Impact of Edentulism on Oral and General Health, Published Online, 2013. May 8. Doi10.1155/2013/488305
  3. National Institute of Dental and Craniofacial Research. The Burden of Oral Disease, 2012.Baltimore, MD: National Institute of Health, National Institute of Dental and Craniofacial Research.
  4. Poss S, Diagnostic Evaluation and Treatment Approaches Used in Dental Sleep Medicine. Compendium 2016 Volume 37, 3:156-162

William Ralstin, D.D.S., Spear Contributing Author
​William Runyon, D.D.S., Spear Contributing Author


Commenter's Profile Image Carlos M.
June 29th, 2016
Great article. Congratulations. One question ¿it,s possible that mouth breathing appears in all? Mouth breathing= hipoxia= simpathetic hyperactivity= GE Reflux Mouth breathing= xerostomy= periodontal disease and decay Mouth breathing= snoring= hipoapnea= apnea I think that in this cases the patient need a polisomnography. Thank you
Commenter's Profile Image Karen N.
July 4th, 2016
Nice article! Do you have any post treatment photos?
Commenter's Profile Image Ron J.
July 11th, 2016
Nice summary. There were some acronyms used in the article, but not identified. Some of them I know, like SEO, and GERD, but can you help me understand what is meant by FH, IMFH, and IFH?
Commenter's Profile Image Bill R.
July 11th, 2016
Good morning Ronald. I am glad you liked the summary. In the article, the acronyms FH, IMFH and IFH are all referring to a fixed detachable implant prosthesis known as a Fixed Hybrid. When a Fixed Hybrid (FH) is delivered at the time of surgery, we call it an Immediate Fixed Hybrid,(IMFH and or IFH). Sorry for any confusion caused by the use of the acronyms.