Discussion

An adequate dentition is essential for a person's wellbeing and basic quality of life. Currently, dentistry is very topical, as the government has suddenly realised that a large proportion of the public cannot access even the most basic level of NHS dental care. We have even heard cases of patients taking their treatment into their own hands and extracting their own teeth. The oral health of the nation, particularly the lower socio-economic group, is being eroded. On top of that, we have an ageing population, many from the ‘sugar boom' generation, who are completely edentulous and have been for many years, resulting in many having an inability to wear complete dentures. Clearly, edentulism is one of the public health burdens for older people and is a devastating and irreversible condition. It is often described as the ‘final marker of disease burden for oral health'. According to the United Nations in their World population ageing report, the number of older adults (60+) in the world has increased considerably in recent years. There were 901 million people aged 60 years or above in 2015, an increase of 48% since the year 2000. In the United States alone, 40 million Americans are missing all their teeth. In Canada, the overall rate of edentulism in 2010 was 6.4%, but 21.7% among adults between 60-79 years of age.1 The rate of edentulism tends to be different from region to region even within a country. Peltzer et al.2 found that the overall prevalence of edentulism was 16.3% in India and 9% in China. Mexico has the higher prevalence rate at 21.7%; Russia comes in second place in prevalence with rates of 18%, and the prevalence in South Africa was 8.5%.

The McGill 2002 consensus statement3 concluded that the quality of life is significantly higher for patients who receive mandibular implant overdentures compared to those who are given conventional dentures and hence mandibular implant overdentures should be the first choice of treatment for the edentulous mandible. This view was endorsed by the York consensus statement (2009) in the UK.4

So, the question is: what has changed in the United Kingdom in the last 15 years to address this issue? Clearly, the percentage of the population who are edentulous may have decreased; however, with an estimated three million patients, many in their later years of life, what is the profession doing to help this cohort?5 Is it acceptable to watch someone who is rendered edentulous move from a Class 3/4 ridge to a Class 5/6 ridge over a period of time? We know that the severely resorbed ridge is clinically and, from a patient perspective, far more challenging to manage with a removable prosthesis.6 Should we jump on the bandwagon of multiple implants and full arch reconstruction that are all the vogue in the implant journals currently?

Could watching this situation of bone resorption in such patients almost be considered as supervised neglect, when we know that there is an intervention that stops this resorptive process?7

The problem is not quite as straightforward as suggested as there are lots of other factors that contribute to this issue. Ellis et al.8 showed that many older, edentulous patients refuse implant-supported overdentures because of their fear and anxiety (relating to the pain of surgery, complications of the procedure and immediate post-surgical denture use), and they question the appropriateness of implants in patients their age.

Let us be frank: conventional dental implants are costly, carry a degree of pain after the procedure and are often time-consuming.

So, why do older patients not seek dental implants when they are edentulous?9 Is it because they can't even access the basic level of NHS care currently and have a set of dentures constructed? Is our current dental profession able to construct and manage the very complex needs of this cohort of patients? Our undergraduates often get limited exposure to denture construction.10

Many edentulous patients are not aware of what they are entitled to on the NHS and they are often fearful of treatment (edentulism clusters in phobics).11 Many of our older patients do not wish to be in pain and cannot afford to pay for an NHS or private set of dentures, far less the additional cost of dental implants.

There could be many different solutions to this issue: a well-constructed set of dentures may suffice for some patients.12 However, those who either cannot tolerate or adapt to this scenario have many other different options potentially available to them. This ranges from the complex full arch reconstruction with dental implants through to the conventional two or four dental implants in the mandible,13,14 to the very straightforward and less costly approach of two mini-implants in the mandible to retain their dentures.15,16 There is increasing evidence that the newer generation of mini dental implants is a viable treatment modality, particularly for the older patient who wishes a less painful and more straightforward solution to retaining their dentures.17

Some may argue that there is no scientific evidence to show, for a patient who wears dentures, although they may be able to eat their food better,18 if there is indeed any nutritional benefit.19 Wearing a set of complete dentures is not just about the potential nutritional benefit for the patient but about the improvement in their overall quality of life.20,21

The area of nutritional benefit and chewing ability is indeed a very complex area, with many confounders impacting on this group of patients,22 including the presence of dental implants,23,24 but the question would remain: should an edentulous patient not at least be afforded the dignity of being able to wear some teeth at least for basic social interaction?

So, should we, as Brånemark said, let: ‘our older, edentulous patients die with their teeth sitting in a glass of water'?

I would ask the question differently: is it acceptable currently to let our older patients live with their teeth sitting in a glass of water?