COMPLETE PROSTHESES TREATMENT – PRESENT AND FUTURE PERSPECTIVES
common restorative procedures. Increased number of trips to see the dentist also adds to patient’ s expenses. Reduced space for complete dentures in dental schools’ curriculum 24, 25, 26 is likely to generate graduates less prepared for the treatment of edentulism. Under these circumstances, it appears that the need / demand of complete dentures exceeds the offer of prosthodontic care within the limitations of existing dental care delivery systems, even in developed countries. The purpose of this paper is to review data on prevalence and future projections on edentulism, also review treatment modalities for this condition. Possible ways to improve efficiency in complete denture treatment, and ameliorate access to care are also investigated.
2. Edentulism and demographics The prevalence of edentulism in seniors observes a wide range internationally, from 11 % in China, to 23 % in Brazil, 24 % in Indonesia, and 26 % in the United
16, 27
States. In Europe, it varies from 15 % to 78 %. In the U. S., the prevalence of edentulism registered a decline during past decades, 28 which can be approximated by a 10 % decline for each decade. 29 Using Census data and projections from 1996( indicating a significant increase in adult population, especially adults over 55), Douglass 30 estimated that the adult population in need for complete dentures will increase by 2020 to nearly 37.9 million, even considering a utilization rate of dentures of about 90 %. 29, 31 It was predicted that even if the estimated decrease in the prevalence of edentulism will follow previous trends, it will likely be offset by the 79 % growth in the population over 55, triggering an increase of the need for complete dentures from 53.8 million( 1991) to 61 million in 2020. 30 The fact that dentures need to be replaced periodically, in order to maintain reasonable function and the oral health related quality of life 32 is also to be considered. Newer data indicate that during the past half century covered by surveys, the prevalence of edentulism in U. S. adults decreased from 18.9 % to 4.9 %. 33 As socioeconomic disparities increased during the same period, edentulism is currently concentrated in the low-income population. 33 The relative decrease in edentulism prevalence in the U. S. by 74 % is comparable with data from other countries: 84 % relative decrease in the U. K. over four decades. 34 A 57 % relative reduction was noted in Finland, 35 84 % in Sweden, 36 and 61 % in Australia, 37 during twodecade periods. 33 In the U. S., the rate of decrease in edentulism is expected to slow to 2.6 % by 2050. Such decline is predicted to be partially offset by population increase and aging, indicating that the number of edentulous individuals will actually decrease by 30 %, from 12.2 million in 2010 to 8.6 million in 2050. 33 In Europe, the prevalence of edentulism is also expected to decrease significantly during the next decades. The growth of the older segment of population is expected to counteract the trends in prevalence, but the effect is not expected to be as dramatic as in the U. S. 7 Prevention of edentulism is work in progress worldwide, with significant disparities, related mostly to access to care and education. Overall, it is likely that the elderly will lose teeth later in life, 38 contributing to an anticipated decrease in the need for tooth replacement, at least in some populations of the developed world.
3. Treatment modalities for the edentulous patient Despite consistent advances in organ and tissue engineering, 39, 40 their current impact on the dental profession and practice is rather limited at best. Dentistry remains predominantly restorative nowadays, and the time when re-growing teeth will become mainstream is probably decades away. The advent of dental implants more than half a century ago brought the hope to evade some of the shortcomings of conventional, tissue supported dentures. Constant development in materials and techniques enabled implant dentistry to become a predictable and lucrative enterprise. If cost were not a limiting factor, implant placement and restoration would be mainstream today, considering the excellent survival rates, even for implants being placed in predoctoral and residency programs. 41 Most studies on implant treatment and oral function demonstrated an improvement of chewing function in the mandible. 13, 14, 42, 43, 44, 45, 46, 47 The implant restorations are well received within the stomatognathic system, with electromyographical activity values comparable to those of dentate subjects. 48 A systematic review by Fueki et al. 11 concluded that a mandibular implant-supported overdenture opposing a maxillary conventional complete denture provides significant improvement in the masticatory performance compared to the conventional upper and lower complete dentures for a limited population having persistent functional problems due to severely resorbed mandible. After implant treatment, patients report high levels of satisfaction regarding various aspects of their denture function and they are more satisfied than patients with similar problems who receive a
13, 44, 49
conventional denture without implant support. Lindquist & Carlsson 50, 51 found that treatment with implant-supported fixed prostheses, generated a significant improvement of the patients’ assessment of their chewing ability, and of the results of chewing tests( particle size reduction and masticatory force). While implant-supported / retained prostheses demonstrated superiority in terms of retention, stability and patient acceptance, especially with fixed restorations, their cost remains prohibitive for a large majority of edentulous patients. During the past decades, using a reduced number of implants was proposed in order to provide the most value for money in such cases, and possibly define a standard of care. The McGill consensus statement proposed a standard of care for edentulous patients, including a maxillary conventional complete denture opposing a 2 implant overdenture. 15 The said standard was
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