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Edentulism: Causes, Implications, and the Role of the Oral Healthcare Practitioner
Thomas M. Bilski, DDS
Many oral healthcare practitioners are unaware of the vast size of the population in the United States with edentulism. This article will review and update the socioeconomic factors and overall health factors associated with edentulism and provide information on diagnosis and treatment planning for the condition.
Edentulism: Definition and Statistics
Edentulism is partial absence or total loss of dentition. As of 2018, the total population of the United States was approximately 327 million people.1 Roughly 36 million of these individuals are missing all their teeth and 120 million have at least one tooth missing.2 The age group with the greatest population of total edentulism is 65 years and older.3This group consists of many individuals who have, throughout a particular period of time, lost teeth due to periodontal disease, poor oral hygiene, or attitude regarding the need for optimum oral health.
According to the Centers for Disease Control and Prevention (CDC), the definition of epidemic is when more cases of disease than expected occur in a given area or among a specific group over a particular period of time.4 Using influenza as an example, if the number of deaths caused by the disease exceeded 7.7% of the total population of the United States in a certain year, it would have been considered an epidemic.5 CDC data show that one of every two adults aged 30 years and older has periodontal disease.6 Table 1 suggests that the US population aged 30 years and older is in an epidemic state of periodontal disease and progressing toward further edentulism or partial edentulism if preventive measures, awareness, and oral hygiene care attitudes do not improve.
Periodontal disease is a chronic inflammatory condition that affects gingival tissue and bone supporting the teeth. Research has shown that periodontal disease is associated with other chronic inflammatory conditions, such as diabetes and cardiovascular disease.7 The responsibilities of oral healthcare providers are to guide their communities in improved oral healthcare practices, provide alternative prosthetic options, and establish relationships with physicians for the edentulous population.
Socioeconomic Factors and Edentulism
Edentulism is one of the most debilitating diseases that can result from a lack of education in proper oral healthcare and oral hygiene leading to caries and periodontal disease.8 False beliefs within the under-educated dental population, such as, "My father and mother lost their teeth and so will I," are common statements in communities with large edentulous populations. Another is, "I don't have insurance and I cannot afford dental care." Where they live and how they were raised plays a role in the attitude of those who are missing teeth. Where there are false beliefs, the "disasters of edentulism" will occur. These disasters are loss of esthetics (looking older), loss of mastication (not being able to eat very well), and loss of enunciation (difficulty in speaking well).
Self-confidence is extremely important within communities. People do not want to look older or lack confidence while speaking and having a meal with friends. Oral healthcare practitioners must be reminded that dentures are not a replacement for teeth but are a replacement for not having teeth.
Lower socioeconomic status, lower income, and rural locations are markers for higher rates of edentulism.9,10 People of lower socioeconomic status tend to ignore dental care until their smiles reach obvious morbidity. Lower-income populations tend to have higher demand for complete dentures for terminal dentition. Individuals who are less educated and less aware are less likely to seek preventive care and may not believe they can afford the high cost of dental care to save teeth.
Time is crucial; as an individual delays dental care or preventive measures, the cost for dental care rises (Figure 1).11 The best dental care arrests the disease process as early as it can be detected. Patients of higher socioeconomic status tend to be more concerned and seek care earlier. They are more likely to have the means to afford dental care and undergo treatment when necessary. These patients more often will seek treatment for partial edentulism with sophisticated dental therapy, such as dental implants or a fixed crown and bridge to treat partial edentulism.
Socioeconomic factors are the most significant determinant of edentulism. The lower the income, the higher the demand for complete dentures.12 Lack of disposable income translates into "wait until it hurts" and the obvious decision to extract teeth and wear complete dentures.
Edentulism and Overall Systemic Health
The mouth is the window to overall health. The mouth is teeming with harmful bacteria that, in the presence of poor oral hygiene, can progressively destroy general overall health. The mouth "talks" to the body, and the body "talks" to the mouth. Equilibrium is needed between oral health and systemic health. Bacteria in the mouth travels to other parts of the body through the bloodstream. Periodontal disease increases the risk of head-and-neck cancer, and tooth loss from periodontal disease increases the risk of Alzheimer's disease. Other conditions that may exist in the body in relation to tooth loss and periodontal disease include malnutrition, obesity, cardiovascular disease, endocarditis, rheumatoid arthritis, pulmonary diseases, and mortality. Without proper hygiene, an increase in harmful bacteria levels presides, leading to oral infections (caries and periodontitis) and a high potential for poor systemic health. Premature births due to periodontal disease during pregnancy are associated with low birth weight, complicated by lack of oral and personal hygiene, socioeconomics, sociodemographics, and smoking.13-15
Oral healthcare professionals need to recognize the effects of systemic health on the oral cavity as well as recognize early development of rampant caries and periodontal disease. Increase in oral disease should prompt dentists to investigate more thoroughly a patient's medical health history and possibly provide a medical referral for an overall systemic health evaluation.
Diseases Affecting the Oral Cavity
Patients with HIV/AIDS or diabetes may develop painful oral lesions. Diabetes may exacerbate periodontal problems due to difficulty for an individual in maintaining blood glucose levels. Both diseases propagate a lower immune resistance to fight infection, creating a more severe oral infection.14,16
Osteoporosis may be linked to periodontal disease, causing bone and tooth loss. Alzheimer's creates an environment for worsening oral health as the condition progresses and oral hygiene care from personal caregivers is lacking. Other diseases that can affect the oral cavity include eating disorders, rheumatoid arthritis, head-and-neck cancer, and Sjögren's syndrome, which creates dry mouth and a progressively destructive system of an increase in caries and periodontal concerns.14,17
Oral Disease Indicators and Medication Concerns in the Edentulous Population
Living a less than healthy lifestyle often presents indicators for oral disease, particularly related to those who are edentulous. The indicators that are quickly identified are halitosis from poor oral hygiene, poor personal hygiene (poor hair and nail care), poor professional care, and smoking. Less-obvious indicators can present in patients with medical conditions that sometimes go undiagnosed, such as rheumatoid arthritis, diabetes, and high blood pressure. Patient attitude or apathy toward total personal and oral hygiene is another strong indicator: "Hey, Doc, I haven't been to the dentist in years, and my teeth are fine. I eat just fine!" The patient attitude of "do not fix it if it is not broken" prolongs the need for care. The delay in care for extended lengths of time is creating a larger population of edentulism as the population matures.
Medications also contribute to oral conditions; patients are often unaware of the side effects of medications. Decongestants, antihistamines, and diuretics to help lower blood pressure can lead to congestive heart failure and kidney disorders through two mechanisms: by direct vasodilation and by decreasing intravascular blood volume through diuresis.18 The crisis Americans are facing from pain killers and antidepressants prescribed for pain management and depression is documented in medical literature and local news sources. All these medications create a decrease in salivary flow.19 When the oral cavity has a decrease in salivary flow, the buffering effect of saliva in the oral cavity is decreased. When the buffering effect decreases, an increase in bacterial acids allows an increase in microbial overgrowth; consequently, patients will have an increase in caries, periodontal problems, and edentulism.
Oral Healthcare Practitioners: Perspective, Diagnosing, and Treatment Planning
Dental educators suggest a decline in dentures in the future because edentulism declined 10% every decade in the last 30 years of the 20th century.20 Declining numbers for edentulism would also suggest that in the future, complete denture curriculum should be removed from dental schools. However, when the increase in the size of the population aged 55 years and older is factored in, the results suggest that the adult population needing maxillary or mandibular complete dentures will increase from 33.6 million in 1991 to 37.9 million in 2020.20 The increased size of the older population offsets the 10% decrease in edentulism per decade. If dental schools choose to eliminate removable denture curriculum in the future, millions of edentulous patients will be in search of denture services.20 Who will be servicing this population, dentists or denturists?
What role does the dentist play in edentulism? This author's perspective regarding the dentist's responsibility is establishing a relationship with the edentulous patient and understanding where this patient is emotionally and in ability to accept the best option available or an alternative for definitive dental services, keeping in mind the patient's ability to afford the proposed patient-accepted treatment.
The realization that oral health can have a significant impact on the overall health and well-being of the nation's population must not be overlooked. Although gains have been made in disease prevention, it must be acknowledged that there are populations suffering disproportionately from oral health problems. The interaction between oral health and overall health and well-being (quality of life) should be evaluated throughout the lifespan of the population in the context of changes in society. Key elements to be addressed in health and disease include focusing on early intervention, prevention, and developing better oral health rather than fixing oral health. In regard to oral diseases and disorders, healthcare providers should follow the evidence for actions to improve oral health throughout each individual's lifetime. The role of the dentist in providing leading-edge technologies and research findings to communities for improving oral health should be considered as a primary focus.
About the Author
Thomas M. Bilski, DDS
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