Tooth Loss, Edentulism, Aging and Geroscience

Teeth are lost for a variety of reasons. It is generally recognized that severe caries accounts for the majority of tooth loss in younger adults, while severe periodontitis is the major cause of tooth loss in middle age and older adults. In adolescents and young adults, permanent teeth can also be extracted for orthodontic reasons, when there is inadequate room in one or both arches to accommodate all 32 teeth, and third molar teeth are often removed due to impingement on second molar teeth.

The complete loss of the adult dentition represents a failure of both personal and professional care, often reflecting limited awareness of the importance of oral self-care, and/or the lack of access to professional oral health care services. This could be due to poor oral health literacy, the lack of available oral health care services, or limited financial resources to pay for professional services.

A discussion of the prevalence of edentulism must consider possible differences between developed and developing countries. A comprehensive review of the global prevalence and incidence of oral diseases was published in 20201Collaborators GBDOD, et al. Global, regional, and national levels and trends in burden of oral conditions from 1990 to 2017: A systematic analysis for the Global Burden of Disease 2017 Study. J Dent Res. 2020;99(4):362-73 https://www.ncbi.nlm.nih.gov/pubmed/32122215.. This study examined the burden of 1) untreated caries in primary teeth, 2) untreated caries in permanent teeth, 3) severe periodontitis, 4) tooth loss and 5) other oral conditions. Prevalence and “years lived with the disability” (YLDs), as well as the change between 1990 and 2017, were reported. To consider the influence of the economic environment, data were provided for high-income, upper middle-income, lower middle-income and low-income countries.

When corrected for age, across the globe, the prevalence of total tooth loss in 2017 was 3.3%. Between 1990 and 2017, when corrected for the change in the population, the percent of edentulism decreased by a little more than 10%. Of interest, the prevalence of edentulism (per 100,000 population) in 2017 by income was 20.3 for high income countries, 103.6 for upper middle-income countries, 130.4 for lower middle-income countries and 116.9 for low-income countries. In terms of the number of persons who were edentulous by income-country categories, these totals were74 million, 120 million, 65 and 8 million, respectively.

The lowest age-adjusted prevalence of total edentulism was seen in countries with the lowest income. This was suggested to be due to lack of an adequate professional dental work force and therefore limited access to care. Quite simply, this is the result of fewer teeth being removed by dental professionals. As a corollary, countries in the highest economic strata had less of a burden of untreated caries and severe periodontitis, but the greatest burden of total tooth loss. In contrast, diet certainly influences tooth loss, and the population in the lowest economic strata have less carbohydrate in their diet, while carbohydrate makes up a larger percentage of the diet in developed countries. Carbohydrates, for example certain sugars such as sucrose, are fermentable by oral bacteria such as Streptococcus mutans, leading to acid production, tooth demineralization and caries development, which impacts the need for tooth removal.

Edentulism represents a defined clinical entity that can be evaluated in relationship to other health measures. In that context, the association of edentulism to mortality has been examined2Friedman PK, Lamster IB. Tooth loss as a predictor of shortened longevity: exploring the hypothesis. Periodontol 2000. 2016;72(1):142-52 https://www.ncbi.nlm.nih.gov/pubmed/27501497. . This review drew several conclusions regarding the link between edentulism and mortality:

  1. “The number of teeth in aging humans can affect longevity and life expectancy.”
  2. “Tooth loss is a predictor of shortened longevity.”
  3. If a person has oral health, morbidity tends to be compressed toward the end of the lifespan.

Recent reports relating severe tooth loss and edentulism to mortality support the hypothesis of an association between these variables.

A systematic review with meta-analysis evaluated the general association of edentulism and mortality, as well as the association of complete loss of teeth with specific chronic diseases (i.e., edentulism and cardiovascular disease)3Romandini M, et al. Periodontitis, edentulism, and risk of mortality: a systematic review with meta-analyses. J Dent Res. 2021;100(1):37-49 https://www.ncbi.nlm.nih.gov/pubmed/32866427.. It was observed that periodontitis was associated with all-cause mortality [Relative Risk (RR)=1.46], as well as mortality associated with cardiovascular disease (RR=1.47), coronary heart disease (RR=2.58), cerebrovascular disease (RR=3.11) and cancer (RR=1.38). This association was not seen for pneumonia. Edentulism was associated with increased mortality due to all-causes (RR=1.66), as well as cardiovascular disease (RR=2.03), coronary heart disease (RR=2.98), cerebrovascular disease (RR=3.18), cancer (RR=1.52) and pneumonia (RR=1.72).

All-cause mortality and edentulism were recently analyzed utilizing data from a longitudinal study of dental status from the Department of Veterans Affairs in the United States. A total of 1,229 individuals were followed longitudinally from 1968 to 2019. Edentulism occurring during the study was associated with a 24% increase in the risk of death, when adjustment for confounding variables4Bond JC, et al. Edentulism is associated with increased risk of all-cause mortality in adult men. J Am Dent Assoc. 2022;153(7):625-34 e3 https://www.ncbi.nlm.nih.gov/pubmed/35241269..

With this same approach, the relationship of the number of teeth to both all-cause and disease-specific mortality was determined from the National Health and Nutrition Examination Survey (NHANES) conducted beween1999 and 20145Yu YH, et al. Number of teeth is associated with all-cause and disease-specific mortality. BMC Oral Health. 2021;21(1):568 https://www.ncbi.nlm.nih.gov/pubmed/34749715.. Here all-cause and disease-specific mortality was examined in relationship to the number of remaining teeth (20-28, 10-19 and 0-9), as well as edentulism and the lack of a functional dentition (0-19 remaining teeth). Having fewer teeth was associated with both all-cause and disease-specific mortality. As examples, having only 0-9 teeth was associated with all-cause mortality [Hazard Ratio (HR) = 1.46], heart disease (HR=1.92), cancer (HR=1.8), as well as diabetes (HR=1.67). Being fully edentulous was associated with increased risk of mortality (HR=1.35), which was also true for those without a functional dentition (HR=1.34). The authors concluded that defining the underlying reasons for this association is the essential next step.

Risk Factors for Tooth Loss

Many of the risk factors for edentulism overlap with the risk factors for noncommunicable chronic diseases, and increased morbidity and mortality. Susceptibility to chronic diseases is associated with lifestyle, including use of tobacco products, excess consumption of alcohol, an unhealthy diet, and a sedentary lifestyle6Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl J Med. 2013;369(14):1336-43 https://www.ncbi.nlm.nih.gov/pubmed/24088093.. Many other risk factors for edentulism have also been identified, including a lack of financial resources and the absence of dental insurance7Simon L, et al. Lack of dental insurance is correlated with edentulism. J Mass Dent Soc. 2015;63(4):28-31 https://www.ncbi.nlm.nih.gov/pubmed/25872285.. A genetic component of edentulism has also been identified8Slayton RL. Genetics and environmental factors play important roles in the risk for periodontal disease and edentulism. J Evid Based Dent Pract. 2006;6(3):238-9 https://www.ncbi.nlm.nih.gov/pubmed/17138453. but teasing out what is truly an underlying genetic basis versus what is an environmental risk factor (a person tends to live in the same place and in the same way as one’s parents) can be difficult. Certain systemic conditions have also been linked to an increased risk of tooth loss. As an example, a recent systematic review identified an association between type 2 diabetes and tooth loss9Ahmadinia AR, et al. Association between type 2 diabetes (T2D) and tooth loss: a systematic review and meta-analysis. BMC Endocr Disord. 2022;22(1):100 https://www.ncbi.nlm.nih.gov/pubmed/35418054., and an analysis of data from the National Health and Nutrition Survey (2011-2018) identified both metabolically controlled and uncontrolled diabetes as associated with an increased risk of tooth loss10Vu GT, et al. Tooth loss and uncontrolled diabetes among US adults. J Am Dent Assoc. 2022;153(6):542-51 https://www.ncbi.nlm.nih.gov/pubmed/35241270..

The absence of most or all teeth represents a risk factor for unhealthy aging. The inability to masticate a fiber-rich healthy diet, and instead consuming a diet of soft foods which are carbohydrate rich, can negatively influence health. Further, the loss of teeth can negatively impact social interaction, which can be another risk factor for chronic disease and premature death.

However, risk factors for edentulism can vary markedly in different countries11Kailembo A, et al. Common risk factors and edentulism in adults, aged 50 years and over, in China, Ghana, India and South Africa: results from the WHO Study on global AGEing and adult health (SAGE). BMC Oral Health. 2016;17(1):29 https://www.ncbi.nlm.nih.gov/pubmed/27465011.. Risk factors for edentulism were evaluated in four countries, where the rates of edentulism differ. India had the highest rate (15.3%) and Ghana the lowest (2.9%), with China (8.9%) and South Africa (8.7%) falling in the middle. In China, the likelihood of edentulism for rural versus urban residents was higher (OR=1.36) but this was not the case in Ghana (OR=0.53) and South Africa (OR=0.52). Those in China with a university degree (OR=0.31) and in the highest wealth group (OR=0.68) were less likely to have lost all their teeth, but in South Africa having a secondary school education, or being in the highest wealth category, were both associated with a higher risk of being edentulous (OR=2.82 and 2.78, respectively). As a further example, when controlling for all variables, participants in India were at 50% greater risk of being edentulous.

Causes of Edentulism

Advanced dental caries and severe periodontitis are both associated with tooth loss, but the prevalence of these outcomes varies over the lifecourse. Other causes of tooth loss include trauma, tooth fracture, extraction for prosthetic reasons, and removal of third molars that cause local dental or mucosal pathology. A recent nationally representative survey of tooth loss in Japan illustrates these patterns12Suzuki S, et al. Reasons for tooth extractions in Japan: the second nationwide survey. Int Dent J. 2022;72(3):366-72 https://www.ncbi.nlm.nih.gov/pubmed/34193342.. In that study the reasons for tooth loss were identified by dentists. Periodontal disease was the major cause of tooth loss in both men and women 65 years of age and older, and dental caries was the predominant reason in persons before the age of 45 (Table 1). However, it is recognized that tooth loss results from a complex interplay of inherent and extraneous factors13Haworth S, et al. Tooth loss is a complex measure of oral disease: Determinants and methodological considerations. Community Dent Oral Epidemiol. 2018;46(6):555-62 https://www.ncbi.nlm.nih.gov/pubmed/29956852.. A large study of two cohorts (from Sweden and South Korea), which included more than 60,000 individuals, assessed tooth loss as a general measure of health status. Longitudinal data was available for the Swedish cohort (>28,000 individuals). Considering the longitudinal analysis, the condition of the mouth at the outset of the study (caries, periodontal disease, existing tooth loss) and demographic and social factors (smoking, education) were most closely associated with future tooth loss. There was an association between the severity of periodontal disease and the number of decayed and filled tooth surfaces (a measure of caries experience) in Sweden but not in South Korea. The authors noted that tooth loss has become a popular means of assessing dental status in population studies. However, they observed that there are differences in the association between dental caries and periodontal disease and tooth loss in different countries and for different age groups in those countries. Therefore, they urged caution in interpretation of tooth loss data when comparing different countries.

Dental Management of Edentulous Patients

An edentulous patient presenting to the dental office for restoration (or with a limited number of teeth that require extraction) requires a thorough evaluation in preparation for rehabilitation. This begins with a comprehensive dental and medical history, including the reason for previous extraction of teeth and a review of current health status, current medical diagnoses, and treatments. The intraoral examination will evaluate the condition of the maxillary and mandibular arches to determine the ridge anatomy in both jaws, the status of the oral mucosa and salivary flow.

Today, there are a wide range of treatment options available to restore the edentulous patient. These range from traditional removal complete dentures, tooth/teeth retained overdentures to implant supported complete dentures that are either removable or fixed.

Fabrication of traditional removal complete dentures is a fundamental dental procedure. However, the outcome of this treatment is dependent upon a lengthy list of prognostic factors14Lee DJ, Saponaro PC. Management of edentulous patients. Dent Clin North Am. 2019;63(2):249-61 https://www.ncbi.nlm.nih.gov/pubmed/30825989.:

Personal factors

  • Age
  • Demographic variables, including financial resources
  • Emotional, psychological, and personal traits
  • Expectations regarding treatment

Technical/clinical factors

  • Prior experience with a denture/removable dental appliance
  • Anatomy including residual ridge form and the depth of the vestibules
  • Changes in the anatomy over time
  • Esthetic concerns
  • How the denture is constructed

Prolonged use of complete dentures is associated with resorption of the alveolar ridge, a process that begins with the removal of teeth. To avoid ineffective mastication, and pathologic changes of the mucosa including ulcer formation, the under-surface of the complete denture (intaglio) should be periodically evaluated, and the soft-tissue surface relined to re-establish proper adaptation of the denture to the ridge. Complete denture patients should be on a regular professional recall schedule for a variety of reason (i.e., screening for oral cancer, adequate fit of the dentures) but this is not always followed by patients.

At present, a major advance in complete denture care has been the introduction of digital denture fabrication (computer-assisted design/computer-assisted fabrication or CAD/CAM). Traditionally, complete dentures were fabricated by first taking an impression of the residual ridges and adjacent anatomy. A model was poured in stone which served as the base for construction of the denture. Recently, a digital approach has been the focus of great interest. Ideally, the image of the residual ridges and neighboring tissues would be captured by an intraoral camera. After obtaining the image, the denture is most often fabricated (computer-assisted manufacture or CAM) using a subtractive approach, wherein a block acrylic is milled. An additive approach is also being studied, where a three-dimensional printing device fabricates the denture. These approaches to fabrication continue to be investigated.

Advantages of digitally fabricated dentures include fewer visits, greater patient comfort, and availability of past records as patients are followed over time. Disadvantages include poor esthetics and altered speech, and occlusal discrepancies. These disadvantages, however, are considered minor. As far as time and cost, an analysis determined that digital workflows are more efficient as well as less costly than fabrication of dentures in the traditional manner15Lo Russo L, et al. Comparative cost-analysis for removable complete dentures fabricated with conventional, partial, and complete digital workflows. J Prosthet Dent. 2022 https://www.ncbi.nlm.nih.gov/pubmed/35660258.. One important consideration is the cost of the equipment needed for digital denture fabrication. This cost could be recouped when the number of denture fabrications increases to between 75 and 900, depending on the type of workflow. Multiple offices sharing such equipment will distribute these start-up costs.

A patient with advanced dental disease, where most of the dentition has been extracted or is scheduled for extraction, can benefit from retention of a limited number of teeth (towards the anterior aspect of the mouth, ideally the mandibular cuspids) to provide stability to the denture, as well as proprioception offered by the retained roots. This overdenture approach generally requires that the retained teeth be treated endodontically, and the occlusal surface access opening sealed with an amalgam plug, or the crown stumps covered with a metal/gold coping. This approach would also retain the height of the alveolus in the areas of the retained teeth. The primary disadvantage is that this approach is increased cost. Retention of the overdenture to the retained teeth can be enhanced using an attachment device such as a ball (on the retained tooth) and socket (within the undersurface of the denture) design. One important consideration is the prevention of caries and periodontal disease of the abutment teeth. A strict oral hygiene regimen is essential which includes the use of a fluoride gel and removal of the overdenture when sleeping.

An entirely new approach to treatment of the completely edentulous patient developed with introduction of osseointegrated implants. In fact, in 2002, a consensus conference stated that an overdenture with two implants is the first choice for restoration of the edentulous mandible16Feine JS, et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontology. 2002;19(1):3-4 https://www.ncbi.nlm.nih.gov/pubmed/12164236.. Other implant-based approaches that have been used include only a single implant in the midline of the mandible, three implants joined by a bar, as well as four or more implants in each arch, with some approaches resulting in a fixed complete prosthesis that can only be removed by a dental professional.

While these implant-based options offer many advantages, the primary drawback is the added cost of the implants. Evidence suggests that acceptance of such treatment by edentulous patients is limited.

In sum, the restoration of the edentulous patient (either one or both jaws), is a more involved planning and restoration process than in the past. The availability of both traditional and newer approaches to restoration of the edentulous patient means that the dentist has a range of options. A decision as to which approach is best for individual patients depends on many variables that are not limited to the status of the oral cavity. The provider must consider the patient’s health status, history of dental care and frequency of recall visits, as well as sociodemographic variables including the patient’s ability to afford care.

Does the Study of Centenarians Provide Additional Insight?

Tooth loss is associated with aging, and therefore the oral/dental status of the oldest individuals in a society may offer insight into the underlying variables associated with the relationship of aging and loss of teeth. A review of recent studies of the oral health of centenarians (persons 100 years of age and older) provides insight into this fascinating group of people.

A study of 162 Dutch centenarians (74% were female) who self-reported as being without cognitive impairment indicated good oral health17Beker N, et al. Self-reported oral health in the Dutch 100-plus Study of cognitively healthy centenarians: an observational cohort study. BMC Geriatr. 2019;19(1):355 https://www.ncbi.nlm.nih.gov/pubmed/31852469.. 76% did not report oral pain and two-thirds said that chewing was not a problem. Nearly one-fifth did reported xerostomia which was associated with use of medication (p=0.001).

83% were edentulous with existing maxillary and mandibular prostheses while 1% were edentulous without prosthetic replacement. Of the dentate individuals, 10% had a removeable partial denture and 6% did not. Of note, utilization of dental services was low, as only 18% of the study population saw a dentist in the previous year. Further, nearly half had not seen a dentist in the previous 10 years. The authors comment that a focus should be on the increasing dental attendance in this oldest-old group, as the number of individuals in this category will continue to increase.

Different findings were reported in a series of studies from Germany, which included 55 individuals who were 100 years of age and older18Sekundo C, et al. Periodontal and peri-implant diseases in centenarians. J Clin Periodontol. 2020;47(10):1170-9 https://www.ncbi.nlm.nih.gov/pubmed/32748427.. In this cohort, dental disease was pronounced, as the mean number of teeth was 9.5 (20 in the cohort were edentulous), and individuals in long-term care had significantly few teeth (mean of 8.5) than those who did not require such care (mean of 17.0). Of interest, deep probing depths about the remaining teeth were not pronounced (mean of 2.7mm) while mean attachment loss was 4.2 mm. Only 4% of teeth demonstrated severe tooth mobility and /or furcation involvement. When the dentate individuals were classified as to the severity of their periodontal disease, 26% had no/mild periodontitis, 55% moderate periodontitis and 18% severe periodontitis.

These same authors examined the prosthetic status of the centenarians and administered a battery of tests to assess cognitive ability and quality of life19Sekundo C, et al. Association of dental and prosthetic status with oral health-related quality of life in centenarians. Int J Environ Res Public Health. 2021;18(24) https://www.ncbi.nlm.nih.gov/pubmed/34948826.. In this cohort, 66% had complete dentures and 22% partial dentures. A third of the dentures needed either replacement or repair, and 16% of the individuals demonstrated denture sores. Further, 60% of the individuals reported unsatisfactory oral health related quality of life, which was directly associated with the number of lost teeth. A further study from this research group examined the oral microflora and characteristics of the saliva. They observed a more diverse microflora was associated with a lower decayed, missing and filled teeth index (DFMT), and the diversity of the microflora was greater in dentate persons than those without teeth. This is an expected finding since the presence of teeth increases the available ecological niches in the oral cavity. Those individuals as defined as demonstrating ‘successful oral aging’ (having at least 20 remaining teeth) also demonstrated a more diverse oral flora, in both the dental plaque and saliva20Sekundo C, et al. Maintaining oral health for a hundred years and more? – An analysis of microbial and salivary factors in a cohort of centenarians. J Oral Microbiol. 2022;14(1):2059891 https://www.ncbi.nlm.nih.gov/pubmed/35401946.. In terms of salivary characteristics, nearly three-quarters had a very low or low stimulated flow rate, approximately half had increased salivary viscosity, two-thirds had a very low or low pH, and 85% had a very low or low buffering capacity.

The authors cautioned that this is a small study, and is cross-sectional in nature, which limits any conclusion about causality. The authors did highlight the importance of changes in saliva buffering capacity and pH.

As populations age, which is occurring most notably in certain developed countries including Japan, the United States, and countries in Western Europe, the percent and absolute number of the oldest-old, often defined as 85 years of age and older, and the percent and number of centenarians, will increase in the next few decades. The available data at this time is limited but suggests that centenarians are affected by the accumulated effect of dental disease, including pronounced tooth loss, and reduced salivary flow. Now looking forward, ongoing studies of this oldest cohort are warranted, as the individuals reaching this milestone will have been born during a period when preventive dentistry was emphasized and there was widespread messaging about the importance of oral health. Ideally, studies should be longitudinal in nature, so the status of the dentition can be assessed over the life-course. Such studies may provide clues about the essentials of healthy oral aging.

Geroscience

The last few years has seen the emergence of “Geroscience”, which is the interdisciplinary study of aging, how the aging process contributes to chronic disease, and by extension defining the biological pathways of aging that can lead to new therapeutic approaches. Here chronic diseases are not considered as individual and unrelated entities, but as having underlying, common causes related to aging. The premise is that aging is modifiable, and that chronic diseases can either be prevented or the progression slowed21Sierra F, et al. Moving geroscience from the bench to clinical care and health policy. J Am Geriatr Soc. 2021;69(9):2455-63 https://www.ncbi.nlm.nih.gov/pubmed/34145908..

Aging has been identified as an important risk factor for oral disease, including periodontitis, root caries and reduced salivary flow, all of which contribute to loss of teeth. Tooth loss is also associated with reduced quality of life22Tan H, et al. Retention of teeth and oral health-related quality of life. J Dent Res. 2016;95(12):1350-7 https://www.ncbi.nlm.nih.gov/pubmed/27466396.. A review of the status of geroscience related to oral disease focused on the animal models used to study oral aging23An JY, et al. Oral health in geroscience: animal models and the aging oral cavity. Geroscience. 2018;40(1):1-10 https://www.ncbi.nlm.nih.gov/pubmed/29282653.. These studies have relied most heavily on mouse models. The authors note that different strains of mice have different lifespans, and “old” mice are not always utilized in some of the published studies. Other animal models including dog models are valuable because while they are evolutionarily as distant from humans as are mice, but they share common environmental variables with humans. Certain types of dogs are affected by periodontitis, which is similar to what occurs in humans. Further, non-human primates have been utilized as models of human periodontal disease, and have contributed to our understanding of the pathogenesis of gingivitis and periodontitis. However, while non-human primate models have also been utilized in a range of geroscience research, the expense associated with non-human primate research is an important consideration.

Today there is a great deal of interest in how oral infection and inflammation are risk factors for chronic diseases. In the context of geroscience, these studies need to consider how underlying mechanisms of aging may explain the basis of many chronic diseases, including oral diseases.

Conclusions

Today, dental professionals should approach extensive tooth loss as more than just a consequence of aging. Loss of the entire natural dentition represents the sum of life’s challenges that can also reflect general health, health literacy and both non-modifiable and modifiable risk factors for poor health (which often are related to lifestyle). There are many considerations that should factor into a treatment decision when replacing the permanent dentition, but clinicians should also focus on the importance of prevention of tooth loss, as a successful outcome that has its origins much earlier in life.

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Table 1.

A. Tooth loss in Japan – Males (percent of teeth extracted)

Caries Periodontal Disease Fracture Orthodontics Impacted Teeth Other
Age
10-14 0 0 0 77 8 15
15-24 37 1 3 16 22 21
25-34 51 6 6 0 18 19
35-44 43 22 10 1 10 14
45-54 37 38 16 0 4 6
55-64 27 50 18 0 1 5
65-74 21 54 20 0 0 4
75-79 20 49 24 0 1 7
80-84 32 40 25 0 0 4
85+ 34 46 18 0 0 2

B. Tooth loss in Japan – Females (percent of teeth extracted)

Caries Periodontal Disease Fracture Orthodontics Impacted Teeth Other
Age            
10-14 0 3 6 84 7 0
15-24 21 2 2 23 37 15
25-34 40 4 4 7 23 23
35-44 45 14 10 2 15 15
45-54 37 25 22 1 4 10
55-64 25 45 23 0 1 6
65-74 26 45 24 0 0 5
75-79 23 50 24 0 0 4
80-84 28 47 21 0 0 4
85+ 28 46 21 0 0 4

Note: percent rows do not always add to 100 due to rounding up or down.
Data from Suzuki et al, 2022 (reference 12)

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