The Impact of Edentulism on Function and Quality of Life
A recent analysis of info rmation collected by the author and his colleagues in Vancouver, British Columbia, revealed that older adults who believe that dentistry is usually painful, or who expect to lose all of their natural teeth, are about three times more likely to report 5 years later that they are dissatisfied with life. Although this does not prove a cause-effect relationship between poor dental beliefs or expectations and poor quality of life (QOL), it does suggest an association. Chapter I noted that the prevalence of edentulism dropped by approximately 10% for each decade of the past 30 years in the United States, yet, because of population growth, especially in older age groups, there will be an increase in the number edentulous patients who have no natural teeth in one or both arches. Hence, the need for dentures will not diminish over the next quarter century and those in most need of dentures are most likely to be among society’s poorest and least advantaged.
Chronic disability now is the major health care challenge of Western society. Consequently, with society’s prolonged life expectancy, there is growing interest in QOL and sensitivity to the “lived experiences” of chronic illness.1 The World Health Organization (WHO) expressed the importance of this sensitivity in 1948 by recognizing health as more than simply the absence of disease and noting that healthy societies have a complicated mixture of social, economic, and cultural characteristics. Edentulism is a prevalent disability with all the characteristics of a chronic illness. It is incurable and functionally and psychologically disruptive. It carries with it a social stigma, and it requires specific management strategies to overcome or limit its disruptive effects.2
Impact of Edentulism on Function
It is widely agreed in clinical discourse that the dentition or, more particularly, the occlusal arrangement of teeth has no direct relationship to the functional health of the temporomandibular joint, other than in extremely unusual situations. The possibility of a dysfunctional relationship has been the source of a long and agonizing debate with serious treatment implications. Studies on the distribution and management of mandibular dysfunction have been hampered generally by disagreements over the validity and reliability of diagnostic criteria or clinical assessments.3 There are reports of chronically abnormal jaw movements attri buted to tooth loss and denture use, but the evidence rests heavily on the identification and interpretation of dysfunction.4 For example, researchers typically identify jaw dysfunction if the maximum separation of a patient’s maxillary and mandibular incisor teeth is less than 40 mm, yet there is no empirical evidence that patients are impaired or even inconvenience by this limited jaw movement.3 Indeed, many complete denture wearers probably limit tooth separation and jaw movements consciously or subconsciously to stabilize and control their dentures. Certainly, stress-induced clenching can damage the denture-supporting mucosa; however, the jaw and temporomandibular joint of most edentulous denture wearers seem to move without restriction or discomfort.
Denture-Induced Mucosal Disorders
Most denture wearers, especially men, have some clinical evidence of denture-induced stomatitis, denture-related hyperplasia, angular cheilitis, or inflammation of the denture-supporting mucosa. Surprisingly, evidence shows that denture quality does not seem to have much influence on the prevalence of these disorders.5 There also is evidence that the risk of oral cancer is elevated synergistically in denture wearers who drink alcohol excessively and who smoke tobacco. Nonetheless, the incidence of oral cancer for edentulous patients is very small, and most of the denture-related pathoses are relatively innocuous inflammatory responses in the mucosa.
Denture-Induced Residual Ridge Resorption
The residual ridge supporting a complete denture is inherently unstable due to unpredictable resorption and remodeling of the alveolar bone when natural teeth are removed. 6 Consequently, resorption of the residual ridge disturbs the comfort and retention of a denture, which, in turn, can irritate the peripheral mucosa to produce an epulis fissuratum. 7 The influence of dentures on the supporting jawbone is unclear. Denture base pressure, especially if it is unevenly distributed on the residual ridge, infected, or structurally defective, can precipitate a low-grade inflammation of the supporting mucosa and the underlying bone,8 but usually the damage is reversible. 9 Clinical experience reveals that the discomfort of an ill-ftting complete denture, especially in the mandible, can be very difficult for the denture wearer to manage. A mandibular residual ridge provides a complete denture with less than one quarter of the support offered by the periodontium to natural teeth, yet some patients expect the prosthesis to replace natural teeth in every respect. Obviously, this expectation is unrealistic and many denture wearers cannot cope with their dentures, no matter how well they have been made.10
Use of Dental Services
The absence of teeth is a principal reason given by the edentate for not visiting a dentist regularly, and patterns of attendance for preventive health care established during youth seem to continue into old age.11-13 In general, people seek medical attention because they perceive that something is wrong, rather than because they detect an objective clinical sign or symptom, and “wrongness” is relative to other people in similar circumstances. Elderly denture wearers, for example, make little ef fort to seek dental care probably because they are surrounded by peers who accept tooth loss and discomfort from dentures with resignation.
Food Selection, Mastication, and Diet
Numerous studies have been conducted on food choices of people with or without natural teeth (see chapter 2), but little attention has been paid to the relationship between the adaptive and coping skills of edentulous individuals and the food they eat. For example, a recent study in the United Kingdom revealed that edentulous older adults with uncomfortable and well-wom complete dentures noted difficulty eating some foods, although most of the group ate nearly all of the food available to them despite difficulties chewing.14 Two thirds of the participants expressed no regrets about this difficulty or impairment, possibly because they managed to adapt and cope successfully with their impairment without undue distress. So, even in this select group of older adults, there was little demand for other prostheses to enhance food selecti/>