“Managing the Edentulous Patient” was recently introduced as a seminar and workshop at Spear Education. In the course, patients are discussed ranging from traditional dentures to implant overdentures and, finally, an implant fixed prosthesis.
Due to the cost and surgical complexity of a fixed prosthesis, many of my patients choose options that are removable. Dentists have informed our patients for years that the proper care of a denture includes the removal of the prosthesis at night to allow tissue recovery and improve oral health. In order to complete the discussion of management of the edentulous patient, we must consider the impact that removing the dentures during sleep has on the patients' ability to breathe.
Prevalence of obstructive sleep apnea (OSA) in patients over 60 can range from 20 to 79 percent depending on the community and criteria.1-3 Edentulism increases the patients' risk for OSA by reducing the size and tone of the muscles of the pharyngeal walls.
The loss of tone is magnified by the loss of vertical dimension and subsequent reduction of lower face height when the teeth are removed. It has been reported that patients with OSA that had their teeth extracted suffered an almost doubling of their apnea episodes.4 Solutions for these patients have included CPAP and mandibular advancement appliances if implants were placed on the lower arch.
An interesting study evaluated the impact of wearing or not wearing a denture during sleep on the level of apnea.3 Home sleep testing was accomplished on elderly edentulous patients with and without their dentures during sleep. 70 percent of the patients with apnea routinely removed their dentures at night.
Wearing their dentures improved the apnea in a majority of the subjects. A reduction in hypopnea, not apnea, explained the recorded change. Therefore, partial obstructions were improved but complete obstruction is only minimally improved.
In fact, in some patients the airway was worsened with the addition of the denture. Of the seven subjects that had an AHI< 5, all normally removed their dentures. When asked to sleep with them, five showed an increase in AHI, none more than five points. Of the apnea group, four patients showed an increase in AHI of greater than five points by including the denture.
As our population continues to live longer, the number of patients facing the unenviable loss of their teeth will continue to grow. The simple fact is that the rate of apnea in the elderly edentulous patient base is significant. It demands that we begin screening these patients when they enter our practices for care.
In addition, edentulating a patient can alter the oral structures so dramatically as to introduce apnea. Follow up for immediate dentures should include apnea screening.
Finally, the removal of the final restorations to improve tissue health and reduce bone loss may, in fact, increase the likelihood and/or the severity of apnea. In the last 7 years, I have changed my protocol for denture patients. I always recommend a screening with high-resolution pulse oximetry with and without the denture. If the denture improves the airway, I will recommend wearing the denture and follow up on the apnea with a physician.
Interestingly, many patients who have been edentulous for a long period of time are reticent to wear their prosthesis at night. They have been told for many years that they will lose bone and be at risk for a fungal infection. I tell them that both are true, BUT that the odds of them being alive to experience those issues goes up dramatically when they improve their breathing.
Jeff Rouse, D.D.S., Spear Faculty and Contributing Author
1. Ancoli-Israel S, Gehrman P, Kripke DF, et al. Long-term follow-up of sleep disordered breathing in older adults. Sleep Med 2001;2:511–516.
2. Ancoli-Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan O. Sleep-disordered breathing in community-dwelling elderly. Sleep 1991;14:486–495.
3. Arisaka H, Sakuraba S, Tamaki K, Watanabe T, Takeda I, Yoshida K. Effects of Wearing Complete Dentures During Sleep on the Apnea-Hypopnea Index. Int J Prosthodont 2009;22:173–177
4. C. Bucca, A. Cicolin, L. Brussino et al., “Tooth loss and obstructive sleep apnoea,” Respiratory Research, vol. 7, article 8, 2006.