Has a patient ever gone against your advice on how to proceed with treatment and they decide to remove all their teeth, only to regret it? Have you ever noticed a visible transformation in a patient when one of the dental treatment options includes the loss of a tooth?
Loss aversion is a fear of losing something you already have, yet it's a primary motivator. In other words, fear is a great motivator.
What if patients were aware of tooth loss consequences? Would they be willing to do more to keep their natural teeth to stave off systemic diseases? Would they think twice before rushing to edentulism and consider other viable treatment options for keeping natural teeth?
If you are interested in helping these kinds of patients, I recommend finding some hands-on learning opportunities related to one or more missing teeth. At Spear, come to the “Implant Restorative Dentistry” workshop and “Restoring the Edentulous Arch” workshop to learn more!
The tooth loss and systemic disease connection
In a 2016 Journal of Prosthodontics article, Dr. David Felton, dean of the University of Mississippi Medical Center School of Dentistry, investigated how tooth loss could be related to systemic disease. Dr. Felton made some eye-opening discoveries for edentulous and partially edentulous patients in the following areas:
- Reported a risk or odds ratio where for every five teeth lost the patient was 1.42 times more likely to demonstrate decreased intake of vital nutrients.
- Showed up to eight remaining natural teeth served to protect against malnutrition in contrast to a patient with one edentulous arch who was 3.26 times more likely to suffer from malnutrition.
- Showed with fewer than eight natural teeth, the patient would be 3.28 times more likely to be obese.
- Evaluated edentulous patients who did not wear dentures and reported these patients were 2.88 times more likely to be obese.
- Found edentulous patients were nearly 13 times more likely to have angina pectoris with younger patients showing increased prevalence.
- Found tooth loss was correlated to increased risk of high blood pressure.
- Found tooth loss correlated to increased carotid artery plaque formation.
- Reported both tooth loss and periodontal disease are associated with increased levels of inflammatory markers in the bloodstream.
- Showed, among other findings, that diabetics were over two times more likely than nondiabetics to wear removable prostheses.
- Reported patients with diabetes were 2.25 times more likely to be edentulous than nondiabetics.
- Reported patients with rheumatoid arthritis had two times the risk of being edentulous than rheumatoid arthritis patients with natural teeth. Interestingly, when patient groups were adjusted for confounding variables, the risk of being edentulous increased to 3.34 times greater than those with remaining teeth.
- Found a nearly two times increased risk of having rheumatoid arthritis when comparing edentulous patients to patients who were missing five or fewer teeth.
- Evaluated more than 500 patients 85 years old and older for three years and reported wearing a denture overnight led to a 2.3 times greater risk of developing pneumonia. This is interesting when we think about airway patients, or perhaps a patient wearing an upper denture over an implant-retained or implant-supported prosthesis.
- Reported 2.37 times greater risk for an edentulous COPD patient to be hospitalized or to die as compared to dentate patients or even partially dentate patients.
- Reported edentulous patients demonstrated 1.54 times increased risk of lung cancer, 2.36 times increased risk of esophageal cancer, and 2.85 risk of bladder cancer.
- Found in a meta-analysis that loss of 6-15 teeth increases the risk of head and neck cancer 1.58 times and loss of 15-19 teeth increases the risk to 1.72 times with the additional finding that completely edentulous patients demonstrate 1.89 times increased risk of head and neck cancer.
(Memory impairment, dementia, challenges in speaking, motor activity, object recognition, ability to plan, and prioritize.)
- Reported in a five-year prospective study a 2.39 times greater risk of cognitive decline for an edentulous patient. Specifically, patients with 1-8 natural teeth demonstrated a 4.68 times greater chance of becoming edentulous within the five-year span than patients with more than eight teeth.
- Found in a meta-analysis a 3.4 times greater risk of edentulous patients developing dementia with the additional finding that these patients had more than six decayed missing or filled surfaces than their control cohort.
- Reported a 91% increased risk for dementia than the partially dentate comparison group. Part of the conclusion was wearing removable prostheses proved beneficial in reducing the dementia risk.
- Reported the number of remaining teeth proved to be a predictor of mortality, specifically stating that each additional remaining tooth decreased mortality over seven years by 4% where the mortality rates during this time were highest in edentulous men.
- Demonstrated a reduced number of natural teeth that were not restored in some fashion was associated with an increased risk of mortality.
- Reported a nearly three times greater risk for mortality of edentulous patients related to stroke were in their conclusions indicated edentulism was a predictor for cardiovascular disease-related mortality.
Consider the options
Over the years, I've had several patients regret their decision to skip my treatment advice and remove all their teeth. What did they regret most? Mostly, their experience with food.
They had quality of life issues pertaining to altered sensations related to the taste, texture, and temperature of food and even wine. Selecting food based on the ability to chew with dentures directly impacts the nutrient intake and overall general health of patients.
Patients were also aware of the functional differences with even a few teeth to assist in chewing and pronunciation, especially at times when they were interacting with grandchildren, friends or while asking for help at the grocery store or pharmacy. The completely removable prosthesis altered daily activities in a way that reduced the enjoyment of their experiences.
On the flip side, I treated a patient who wore a lower partial retained by the two canines for 12 years before moving forward with a three-dental-implant-supported fixed bridge restoration (Fig. 1). The patient worked diligently to maintain their two remaining teeth, and truly altered their lifestyle to include exercise and healthy food choices for the best nutrient intake.
The idea of working with dental implants to return to the level of function expected of natural teeth helped expand their options for eating the types of food consistent with a healthy lifestyle and became a huge motivating factor in moving forward with this type of transformation.
The time and effort dedicated toward keeping the two canines healthy over 12 years helped to translate into the care required of the dental implant-supported restoration. The restorative treatment led to a long-term, low-maintenance outcome.
Here's an example of a patient who was edentulous in the upper arch opposing lower complete natural dentition. This type of patient was functionally edentulous simply because of the “weak point” in the upper denture.
Patients like this are fully aware of the differences between living with natural teeth and living with a prosthesis made to work in the absence of teeth. How can restorative dentists influence these kinds of patients to keep teeth and perhaps improve their overall health and lengthen mortality? An upper denture opposing a lower dental implant-supported hybrid would work (Fig. 2).
The patient presented with a severely worn upper denture made originally as the upper teeth became structurally compromised due to parafunctional habits. The patient grew frustrated with the dental work and elected instead to have the upper teeth removed. Once the upper teeth were gone, maintaining the lower teeth became a priority of greater importance.
We worked with an upper denture to identify the tooth position that supported the upper lip while allowing for the natural movement patterns of the lower jaw. This is an important step in the process prior to proceeding with a dental implant-supported restoration, where the goal is to improve the function and appearance in a durable manner.
This patient reported no findings when he discussed his health history – a healthy 55-year-old male who had not likely visited a physician in decades. What would dentists need to watch for as the patient returned for recall visits?
Discussions around nutrition proved beneficial to the overall health of this patient. Vitamin B absorption becomes increasingly inefficient with age and is important along with Vitamin C to maintain oral health.
Obesity and hypertension can be observed in the dental setting with a direct clinical correlation to airway and risk of developing sleep apnea. The increased risk of head and neck cancer increases with loss of as few as six teeth increasing the focus in the extraoral and intraoral examination.
Observation through discussion for diabetes, rheumatoid arthritis, respiratory diseases, and cognitive decline may help to motivate a patient to present for an evaluation with a physician.
What about a patient who lost a few teeth and is straddling the gray zone of what could be considered the terminal dentition state and is feeling the sting of loss aversion? This patient wanted to keep their remaining teeth if possible (Fig. 3). Is there a way to phase treatment and think ahead to what would be next in the process?
The experience of this patient was that whenever something happened to cause pain or discomfort, the offending tooth was removed. At this point in time, the patient was insistent on finding other options that would afford the opportunity to keep the remaining teeth.
Simply restoring with a conventional removable partial denture would increase the risk of tooth loss for the lateral incisor #10 (Fig. 2). The goal was to work with a forward-looking, less involved treatment plan in terms of surgery, should the need arise to transition into an edentulous arch strategy.
The patient's health history included:
- Hypertension and previous stroke (tooth loss correlated with high blood pressure, as well as carotid artery plaque formation).
- Adult onset type II diabetes (two times more likely to wear removable prostheses).
- Previous cigarette smoker (greater than double the risk of developing pneumonia and mortality with hospitalization, along with COPD).
- Anemia, fibromyalgia, and depression, as well.
During recall appointments we looked for findings related to rheumatoid arthritis, as dexterity could impact how he was able to clean and maintain the remaining dentition. Any signs of head and neck cancer and evaluating through discussion for signs of cognitive decline and the ability to check and maintain a stable and healthy A1C. The nutrition discussion was also important with the patient as he worked through this process.
What about a young patient who endured a traumatic injury? What are some potential treatment options to set the patient up for a positive dental experience for years to come (Fig. 4)?
This patient has 25 of 28 teeth at 20 years of age. The obvious restorative treatment option focused on a dental implant-supported fixed bridge restoration central to canine. The missing anterior teeth happened to be in a very visible and highly expressive area of the face. At this point in time, there was no concern reported in the health history where odds ratios become a point of focus.
The goal was to limit the impact of the traumatic injury and tooth loss that occurred. Clearly, the idea was to influence the patient to maintain the supporting structures and the adjacent teeth in a manner different than other areas of the mouth.
How would the general health and nutrition impact the overall result over time? At what point would there be conversations with the patient to influence the priority of overall health and well-being?
Dentists have an opportunity through recall appointments to influence patients over time, even more likely with direct contact than a 20-year-old would have with their physician. A prevention-oriented focus for this patient had the potential to positively impact the patient's overall health and well-being for a lifetime.
Options stem from education
Finally, in the event you are thirsty for more statistics, think about this information:
- At age 65, 50% of Americans are missing at least six teeth.
- 56% of our patients 75 years old and older are edentulous in one or both arches.
- The average adult 20 years old and older has just under 25 teeth.
In his article, Dr. Felton alludes to the significance of missing teeth in an edentulous patient as meeting the World Health Organization's (WHO) criteria for being physically impaired, disabled, and handicapped. I am energized by the opportunity to work through dental solutions for these patients.
When I can work with a patient who has experienced the functional limits of complete denture and is looking toward a regenerative treatment plan, I'm excited to provide that type of outcome. The patient's response to the overall treatment reinforces my desire to help people achieve a level of function that is appreciated and enjoyed in a variety of scenarios.
The life experience and the quality of that experience truly enhances appearance, facial expression, verbal expression, as well as function, including noticeable improvements in taste, temperature and texture, along with the ability to chew anything available on a menu.
Douglas G. Benting, D.D.S., M.S., F.A.C.P. is a member of Spear Resident Faculty.
Felton DA. Complete Edentulism and Comorbid Diseases: An Update. Journal of Prosthodontics. 2015;25(1):5-20.
Felton DA. Edentulism and Comorbid Factors. Journal of Prosthodontics. 2009;18(2):88-96.
Ioannidou E, et al. Tooth loss strongly associates with malnutrition in chronic kidney disease. Journal of Periodontology. 2014;85:899-907.
De Marchi RJ, et al. Number of teeth and its association with central obesity disorder in Southern Brazilians. Community Dental Health. 2012;29:85-89.
Nascimento TLHD, Da SDD, Liberalesso NA, Balbinot HJ, Neves HF. Association between underweight and overweight/obesity with oral health among independently living Brazilian elderly. Nutrition. 2013;29(1):152-157.
Medina-Solis CE, Pontigo-Loyola AP, Perez-Campos E, et al. Association Between Edentulism and Angina Pectoris in Mexican Adults Aged 35 Years and Older: A Multivariate Analysis of a Population-Based Survey. Journal of Periodontology. 2014;85(3):406-416.