January 2009, Volume 5, Issue 1
Published by AEGIS Communications
Dentures and Implants: Bringing Them Together For A Winning Combination
Allison M. DiMatteo, BA, MPS
Dentures and implants are not mutually exclusive. On the contrary, implants can provide stability and predictability for dentures, making them a more comfortable and stable prosthetic option for edentulous patients. Cited benefits of implant-supported and/or implant-retained dentures include better quality of life, enhanced self-confidence, improved nutritional state, and better facial esthetics.1,2
Discussions shouldn’t focus on the relevance of dentures in the age of implants, per se. Rather, they should focus on the relevance of dentures to clinical practice, to dentistry in general, and how the implant community can help manage better denture comfort and clinical functionality.
Jocelyne Feine, DDS, MS, HDR, a professor in the faculty of dentistry at McGill University, notes that even though the materials and the techniques for denture fabrications have changed over the years, conventional dentures are pretty much the same as they have been for hundreds of years—even back to and before the time of George Washington. They’ve always been designed to fit over a ridge of bone and soft tissue, and the bone constantly deteriorates over time. There is very little for a denture to hold onto, and patients try to keep their dentures in place with their tongues, cheeks, and lip muscles, Feine says. Even just a couple of implants retain and stabilize dentures, thus providing better comfort and function.
“Dental implants to support denture function for the completely edentate patient is well documented in that it does provide patients with an opportunity to gain stability for their dentures,” comments Lyndon F. Cooper, DDS, PhD, chair and graduate program director of the department of prosthodontics at the University of North Carolina School of Dentistry. “My colleagues and I just published a paper showing that patients who receive implants at the time they receive their dentures do extremely well, and that they have notable improvements of things beyond denture function, such as how they view their own facial appearance. These are very strong reasons to include implant therapy in denture treatment.”
Exploring the deeper issues of relevance uncovers an evolution in the oral health of at least the US population for the next foreseeable 30 years. Edentulism will decrease, but the elderly population will increase, and this is expected to keep the numbers of people needing dentures constant until between 2020 and 2040.3,4 Therefore, the need for well-educated and skilled general practitioners and prosthodontists capable of providing specialty clinical care to these patients must continue to increase annually in order to meet projected needs. According to Ronald L. Rupp, DMD, senior director of external relations and institutional advancement for the American Dental Education Association (ADEA), although the population has changed and will continue to change, the need for removable partial and full dentures is not going away, as reported in a study published by Chester Douglass, DMD, PhD.3
“Clearly, the number of patients who have no or some missing teeth is on the increase, and all the projections continue to suggest that the number of those types of patients will increase over the next 30 to 50 years,” believes David A. Felton, DDS, MS, a professor in the department of prosthodontics at the University of North Carolina. “I would have to say [that it is my opinion] that probably the majority of dental school graduates right now are not trained to a level of clinical competence in complete denture therapy, possibly not even in removable partial denture therapy, whereas the specialty of prosthodontics does train people to very high levels of competency in those areas.”
Nash and Pfeifer4 have noted that while increasing enrollments and graduates in dental schools represent favorable trends for growth in prosthodontics, there remains concern over the prosthodontics training curriculum. Specifically, there is concern for the long-term consequences of decreasing exposure and development of clinical skills in the undergraduate prosthodontics curriculum. As Waldman and colleagues question, is it time to again consider legalizing independent denturists?5
According to Robert Chapman, DMD, chair of prosthodontics and operative dentistry at Tufts University School of Dental Medicine, the continued need for prosthodontists today has to do as much with the complexity of the case as anything, and that also relates to standards of care. If a patient presents with a very complex problem, either for a denture or any other restorative treatment, the complexity is better addressed by somebody who has an advanced understanding of what the standards are and has been trained to work toward those standards, Chapman explains.
“The prosthodontic specialty, like surgery, endodontics, and periodontology, has developed standards within the specialty, and students are trained to those standards, not just to minimal competency,” Chapman says. “If patients present with really complex problems, somebody who is trained to a standard within a specialty program is probably going to be better able to serve that patient well. Graduates of specialty programs have been trained at a higher standard of competency and care established within the specialty.”
This month Inside Dentistry reaffirms the relevance of dentures and their growth in the market in an implant era. Simultaneously, and perhaps most importantly, this month’s feature confirms the continued need for the prosthodontic specialists who provide the clinical care in concert with general practitioners in order to deliver quality denture prostheses to those who need them. Further, our feature examines what is required today in terms of didactic prosthetic courses and clinical experiences in order to cultivate an appreciation for the needs of today’s edentulous patients.
What the Demographics Suggest
Providing full dentures involves a sector of prosthodontics that is not necessarily going to grow as much as dentistry will be challenged by who is going to provide the service, explains Dave Avery, AAS, CDT, director of training and education for Drake Precision Dental Laboratory, referring to the Douglas article.3 Avery says that one of the interesting things discussed in that article is that the number of edentulous arches—not patients but edentulous arches—would increase from 33.6 million in 1991 to 37.9 million in 2020.
“This study really coincides very precisely with all things that we have seen from the federal government’s studies regarding the baby boomers and that very generation that is going to require treatment,” Avery says. “Even though there is a smaller percentage of those patients that is edentulous than what we’ve historically seen, the sheer size of that group brings us a very large number to treat. I think one of the things that has to be discussed as much as anything is the available number of clinicians, qualified dental technicians, and laboratories to provide service in conjunction with that baby-boomer generation expansion.”
Rupp outlines just what kind of numbers we’re talking about in terms of the population of partially and fully edentulous patients in the years ahead. The fastest-growing segment of the US population is the 55+ age group, the baby boomers. Because there will always be the need for continuing good oral healthcare for the aging adult population, this patient population does present challenges both today and in the future in terms of its care. Current dental professionals and newly graduated clinicians of tomorrow will have to continue to address these challenges, Rupp says.
“According to Chester Douglass, DMD, PhD, by the year 2020, he estimates that in the adult population, those patients needing one or two complete dentures will approximate 37.9 million adults, a significant increase over the 33.6 million in 1991,3” Rupp says. “On top of that, there may also be an increasing need for removable partial dentures.”
Therefore, Rupp says, the dentist population—the general dentists and prosthodontists—will still need to provide treat-ment for patients needing partial and full dentures. As a result, what will be needed in dental schools is a comprehensive and appropriate educational experience for the predoctoral dental students across the United States—as well as in the postgraduate, postdoctoral courses in prosthodontics—that focuses on removable prosthetics and fixed prosthetics, he says.
According to Michael A. Gaglio, DDS, vice president of marketing for Ivoclar Vivadent, the need for dentures has continued to increase, as evidenced by the denture tooth market. Even with the strong growth in preventive and alternative restorative care, the demand for dentures continues to grow, interestingly enough coincident with growth in implants, he says.
“I think implants solidify the quality of denture care, and the standard of care for an edentulous patient today is more often becoming an implant-supported and/or retained denture,” Gaglio admits. “Whereas in the past clinicians may have been intimidated by implant denture treatment options, we’re now seeing a growing interest to provide patients with implant-supported and/or retained complete denture treatment. Perhaps this growing interest on the part of clinicians is a reaction to the growing requests of the patients themselves to have their dentures supported by implants. Patients today have unprecedented access to information via the internet, and they are not timid about asking questions concerning their treatment.”
Cooper echoes earlier sentiments, noting that prosthodontics is more relevant today than it ever has been because the complexity of therapies requiring specialty care is ever prevalent and growing in its need. One example is the continued existence of the edentulous patient.
“We know that there will be for at least the next two decades an equal number of edentulous patients in this country alone. In other parts of the world, the numbers of the edentulous patients will increase,” Cooper says. “But back to the United States, there is not going to be any reduction in the number of edentulous patients.”
Another example is the complexity of care of patients with restored teeth, which creates a second need for specialty care, and that is the patient with the 20- and 30-year-old rehabilitation that is now failing. Many times the choices of treatment come down to one, and that is removal of the failing teeth and restorations and the replacement of those teeth with dentures and preferably implants, Cooper explains.
“Those types of procedures often fall beyond the scope of comfort or even the scope of education of a general dentist. There has to be an opportunity for patients who deserve and need specialty care to seek it,” Cooper believes. “So, I think that prosthodontic care in terms of prosthodontic specialty will remain relevant.”
The Role & Responsibility of Dental Education
According to Felton, one of the things that has occurred in prosthodontic education over the past 20 years is a reduction in the amount of curriculum time. During the mid 1980s, approximately 20% to 30% of curriculum time at dental schools nationwide was cut back due to some perceptions about reductions in the number of edentulous, or partially edentulous, patients that would need to be treated, Felton explains.
“Interestingly, now that dental implants have become fashionable in the American marketplace, more and more dental school deans are interested in placing dental implant education into the curriculum of the school,” Felton says. “The question that always arises is, ‘What will be given up to enable something else to be put in?’ Probably one of the easiest places to start dental implant education is with the completely edentulous or partially edentulous patient. The problem is that if you’ve cut the curriculum already, and you’re adding implants in, something else has to give in the curriculum.”
Felton admits that there’s a bit of a disconnect in terms of what needs to be done. He would encourage dental school deans to consider enhancing their complete denture and removable partial denture curriculum, as well as incorporating dental implant therapy as part of that.
In order to better emphasize the skill sets needed for providing partial or complete dentures in today’s practices, Chapman believes that prosthodontic education should be more case based and not just procedurally based. In other words, if dental students are presented with a patient problem and a diagnosis that is based upon not only an intraoral examination but also a medical and dental history, then the information is there for them to perform a procedure or procedures in a certain way.
“In this way students begin to associate a patient problem with a particular technique versus teaching a technique and then applying it almost willy-nilly to the patient,” Chapman says. “Not all patients who are partially edentulous should have a partial denture, for example. They may be better served by either doing nothing or having implants placed, but implants can only be placed if there is sufficient bone. So you can, for instance, provide different cases with different parameters.”
Rupp looks at further enhancing the educational experience for the approximately 18,000 to 19,000 predoctoral students across the 57 dental schools in the United States in another way. He suggests that while dental school educators can continue to teach and master the diagnostic and clinical techniques related to partial and full dentures, the scope of the curriculum could be widened to examine the process a patient undergoes during tooth loss to explore the psychological implications and to more fully understand and manage the quality of life issues that patients experience.
“Where it is not currently being addressed, predoctoral and postdoctoral education really needs to look at enhancing the educational experience to address these quality of life issues, including the psychological aspects of the loss of the natural dentition,” Rupp suggests. “What is that patient sitting in the dental operatory experiencing as they lose that first tooth to the point where they may lose the entire dentition and are fully edentulous?”
In this regard, Feine reminds us that edentulism is a chronic condition, something that cannot be treated and cured; that the World Health Organization has defined an impairment as the loss of any body part, and disability as the inability to perform acts necessary for life (eg, chewing for nutrition); and, therefore, that all patients who are edentulous are impaired, with many being disabled. She adds that those who are very self-conscious about their dentures, refusing to engage in social engagements and interactions, are also handicapped.
“All we can do is provide them with a device that is meant to improve their function and their quality of life,” Feine says. “We, who are academics, have a responsibility at the dental school level to train our students so that they will be able to understand how to evaluate new technologies and make the best decisions when considering patient care, so that they will be able to inform or provide the most recent evidence-based therapies/technologies to every patient.”
Cooper notes that it’s important to do two things in terms of enhancing prosthodontics education. The first is to reinforce the age-old skills that are based on quality of procedures, and there’s a long laundry list of the things prosthodontic specialists do, he says. That list involves an ability for a clinician to actually handle the materials used to make dentures. More importantly, is to move beyond the notion of treating a patient without teeth by focusing on making a denture, Cooper emphasizes, reiterating similar opinions.
“I think prosthodontic education needs to move to understanding the care of the edentulous patient, and that involves a lot more than just wondering if they have made a good impression or they have set the teeth in the right place,” Cooper says. “It’s a real challenge for educators to regain focus on comprehensive treatment of the edentate patient. It is more than going to a denture clinic or going to a denture laboratory.”
Another factor in terms of how prosthodontic education could move in a positive direction would be incorporating evidence for success of particular procedures, as well as what the evidence is based upon, Chapman says. Using partial dentures as the example, he suggests incorporating evidence regarding the most appro-priate types of major connector to use. There is evidence, although not a lot, to suggest what patients find most comfortable as far as a major connector, he says.
Further, implants are a big area for the future treatment of the edentulous and partially edentulous patient, and students, both in predoctoral education as well as graduate education, need to know more, Chapman says. Implant placement and implant-supported prosthetics need to be a big part of all prosthodontic training, he adds.
“However, it should not only be training in the placement of implants, but training in the diagnosis and how the diagnosis affects the various techniques or treatments we’re going to be providing for the patient,” Chapman explains. “No longer should prosthodontics or predoctoral training be on technique or just how to do something, but on why to do it as well as how to do it based on evidence.”
Cooper says that at the University of North Carolina, undergraduate dental students who have just completed their preclinical education in crowns and bridges and implants and dentures are given a complete didactic course in implant therapy. He says the instructors suggest to students that dental implants are a very good clinical way of improving the patient’s perceptions and their own ability to manage patients’ care if they don’t have any lower teeth.
“The problem with all of this is that we often lose sight of the goal and we get very focused on the implant as a technological device. These training programs really need to be very patient focused, and we need to remember that we’re taking care of our patients,” Cooper emphasizes. “The implants are a wonderful opportunity for these individuals to gain better function beyond their dentures.”
Regardless of the specifics of how predoctoral and postdoctoral prosthodontic education will be enhanced and appropriately addressed in the overall dental school curriculum, Rupp asserts that ADEA represents The Voice of Dental Education. Maximizing all of the educational experiences—whether for the future or current practicing dentist, the future or practicing dental hygienist, the postdoctoral prosthodontist, or the postdoctoral periodontist—is at the center of everything the organization does, he explains.
“As dental educators look at their curricula and the time spent in and around the removable full and partial denture experience, ADEA can perhaps be a leading voice of dental education as it develops its programs,” Rupp says.
The Era of Implant-Retained Dentures
Any edentulous person or any person who is going to become edentulous, especially the younger person—whereas in the past dentistry primarily focused on overdentures for the older population—will benefit from implants, explains Robert C. Vogel, DDS, a private practitioner in Palm Beach Gardens, Florida. Implants will maintain bone or significantly slow the progressive loss of bone so that in their later years, younger patients will still be able to wear a prosthesis.
The primary reason is to replace missing teeth, as well as missing hard and soft tissues—such as those caused by continued resorption of the maxilla or mandibular bone. Further, anybody who’s edentulous and is having chronic soreness or an inability to eat properly or get proper nutrition will benefit from implants, not only in terms of comfort but also with social as well as psychological and physical improvements, Vogel says.
Hearing his patients say, “This has changed my life,” is the most significantly rewarding aspect of providing implants to denture patients, believes Vogel. He highlights the obvious initial improvements: enhanced retention of the denture, decreased sore spots, significant improvement in comfort. Then, visible changes can be seen in patients in terms of relaxation of their facial muscles, significant improvement in their confidence, increases in their social interactions, and long-term improved health through the ability to eat better and choose different foods by not being limited by their dentures, he says.
But the research speaks the loudest. Feine and her colleagues have conducted numerous clinical trials6-8 including studies involving groups of edentulous patients randomly placed into groups either getting brand new conventional dentures made by prosthodontists or implant overdentures with a minimum of two implants in the anterior mandible to hold their dentures. Patients were asked about their satisfaction at 3 months, 6 months, 1 year, 2 years, and 5 years after they received their new prostheses. Questions focused on social interaction, sexual activities, quality of life, and diet and nutrition.
“What we found is that the people who received the implant overdentures were significantly more satisfied with the treatment, with their ability to chew a variety of foods that ranged from very soft, like soft bread, to very hard, like pieces of raw carrots, than the people who received new, very well made, conventional dentures,” Feine says. “We also found that the oral health-related quality of life of people who received the implant overdentures was significantly better than the people who received the new conventional dentures.”
Preliminary evidence also suggests that people who received the two-implant overdentures had significantly better nutrition than people who received the new conventional dentures, Feine says. Although the two groups weren’t compared directly, those who received the two-implant overdentures had significant increases in their blood serum levels of hemoglobin, albumen, and vitamin B12. “This is a very promising finding, suggesting that people who are missing all of their teeth will actually modify their diets once they have dentures that are more stable, because they can eat healthier foods,” Feine says.
Fortunately, there is a wide range of implant-assisted therapies for retaining dentures, explains Cooper. When referring to retaining dentures, we’re talking about overdentures. Even a single implant can be used, Cooper says, noting that when researchers have looked prospectively at the ability to use just one implant to retain a denture, patients have experienced benefit and have seemed to do quite well.
The traditional method of using just two implants to retain a lower denture seems to be almost the standard in the literature, Cooper observes. When looking for comparisons of different implant procedures to retain dentures, there is not much comparison being done between one versus two or two versus four implants to retain overdentures.
“What is clear is that studies show benefit to the patients and success with the implants,” Cooper says.
Despite cost and financial limitations, Feine points out that when dentists begin to see their edentulous patients, the first treatment that should be suggested is an implant treatment. She notes that, based on the scientific evidence, dentists have an ethical, professional, and legal obligation to at least inform their patients about implants to support their dentures.
“Dentists have the same obligations for any treatment that is scientifically shown to be more efficacious than what is presently being provided. This applies not just to implants, but to any new therapy option that is introduced for which there is scientific support such as that for implant treatment,” Feine explains. “Dentists must be aware of this information, and they have an obligation to fully inform their patients about all scientifically based treatment alternatives, even if they do not offer that therapy in their own practices.”
Dentures & Implants—Together for the Better
Implant-retained dentures can provide patients with comfort, improved self-confidence, and stability. The dental team (ie, general dentist, prosthodontist, implant specialist) can work together to successfully combine these two treatment modalities. Doing so requires adherence to proper protocol, treatment planning, and material/patient selection.
As explained by Robert C. Vogel, DDS, there is a difference between implant-supported and implant-retained dentures. An implant-supported denture includes the implant and associated abutments supporting the occlusal forces and any function that goes onto the denture. The majority of denture cases for which implants are placed are implant-retained dentures, which means the implants are there to retain the prosthesis in the mouth and provide stability to the prosthesis, Vogel says. The actual occlusal forces are supported by the residual hard and soft tissues.
According to David A. Felton, DDS, MS, the specialty standards for prosthodontics has implant placement for dentures as part of the requirements for training programs because specialists must have experience in the surgical placement of implants. Although the implant placement training varies from residency program to residency program in terms of how involved they get, Felton notes the combination of implants and dentures as being a real growth area in the prosthodontics specialty training.
Vogel clarifies that when talking about implant-retained dentures as a traditional implant overdenture, there are different types of removable, full implant-retained dentures. These include those retained by individual attachments, such as a prefabricated attachment (eg, locator attachment) or an individual custom abutment or telescopic abutment that a laboratory would fabricate, and splinted attachments, he says. Splinted attachments could refer to a bar that is either cast, milled, or, today, fabricated through the use of CAD/CAM, where the implants are still there to provide retention for the prosthesis, but the implants are splinted together, Vogel points out.
There are also hybrid appliances (eg, fixed detachable), which is a denture being supported by the implant whereby only dentists can remove the appliance by unscrewing it; the patient is not able to remove it. Another option is a traditional, fixed appliance for the fully edentulous patient that would be fully supported by implants and not by the hard and soft tissues.
“The factors that need to be taken into account when treatment planning between the types of implant-retained dentures—meaning, whether you use individual, nonsplinted attachments or splinted attachments or a hybrid—include the patient’s ability for hygiene,” Vogel emphasizes. “Certainly a fully removable appliance is easier to maintain hygienically, as well as in terms of cost. Most often individual or nonsplinted attachments will have a lower cost for the patient.”
Overall, the benefits of implant-retained dentures are overwhelming, Vogel says. The most outstanding or obvious initial benefit that he’s seen as a dentist is the improved retention of the appliance, as well as a significant decrease in sore spots.
“But the biggest change I’ve seen is the improvement of patients’ quality of life, and this improved quality of life is translated into the patients’ confidence,” Vogel says. “Once they have a denture that they know won’t move or fall out of their mouth, all of a sudden you start to see their facial muscles relax, and their facial appearance is greatly improved.”
Dave Avery says that the availability of very sound science to support the surgical procedures and the use of direct attachments to retain and stabilize dentures is opening up a huge market sector. Of all edentulous arches, statistics show that less than 2% of patients who could use implants to support their dentures have been treated as such. This, he says, represents an upside for dentistry.
“There’s been an introduction of simplified, streamlined procedures that are making it more cost-effective to provide implant therapy to patients and more affordable to that strata of the population that may not have as much expendable income,” Avery elaborates. “Predictions by the manufacturing communities throughout the world suggest double-digit growth for implant dentistry. Therapy of either transitioning patients with existing dentures or patients who are becoming edentulous and supporting them with implants is a tremendous service to the public.”
Felton says that there is an emerging body of information coming out about the combination of reduced-diameter or mini-implant therapy and complete denture therapy—which can also be applied in an immediate-load type of scenario—but he says that for the mini-implant part, the data is limited. As far as extracting teeth, placing implants and immediate dentures, Felton says that the appropriateness of those procedures depends upon the case.
According to Robert Chapman, DMD, almost all of the implants that are on the market will osseointegrate, and there is now some evidence that the mini-implants will, also. To secure a denture to the mandible, the evidence (research-based articles) says that two implants are sufficient, he says.
“Two implants in the mandible will work to help maintain and stabilize a denture,” Chapman says. “There’s been research done on one implant, three implants, four implants. It’s safe to say, within reason, that four or five implants are probably going to hold a denture better than one or two, but that depends upon how easy it is to place the implants and their angulation once they’re placed.”
“The most significant treatment-planning consideration is the angulation of the implant,” Vogel says. “If significant angulation correction needs to be made in order for the appliance to be inserted and removed, then that would be the primary indication to fabricate a bar or a splinted attachment, where the laboratory can correct for mal-aligned implants.”
Do Denture Patients Need Denturists?
Obviously the question of whether dentistry is facing an age of needing denturists is a politically sensitive issue within the organized aspects of dentistry, explains Dave Avery. However, the current access-to-care issue is certainly on the minds of everybody in the dental profession, and it’s a very key point.
“There is nothing necessarily or inherently bad about being trained to do just dentures,” explains Robert Chapman, DMD. “The issue is diagnosis, and it’s not only diagnosis of the problems with the mucous membranes of the mouth or the residual ridge of the mouth. It’s diagnosing what the problems are that one might see on a radiograph: a cyst, for instance, or a tumor. Are denturists trained in those areas? The answer is no.”
Among the characteristics identified during a comprehensive examination that need to be diagnosed are the Angles Classification and the relationship between the maxilla and the mandible, Chapman elaborates. How are size discrepancies or Class III relationships diagnosed? What are the patient’s abilities to function based upon the severity of Angles Classification?
“One needs to be well grounded in all of the information necessary—skeletal relationships of the upper and lower jaws, radiographic analysis, mucous membrane health, other diseases based upon examination of the head and neck, other factors in the patient’s life that could affect denture comfort and oral health (eg, medications causing dry mouth that might affect denture retention) of the denture—to properly diagnose a patient,” Chapman says. “The individual making a diagnosis should also be able to discuss other issues with patients, such as placing implants to help retain a denture on the mandible where there are insufficient structural remnants, like a residual ridge to help hold the lower denture in place.”
According to Lyndon F. Cooper, DDS, PhD, prosthodontic education requires that dental professionals treat patients and not make things. When talking about providing dentures for a patient, making the denture is just a very small part of taking care of an edentulous patient; therefore, Cooper strongly believes that the comprehensive treatment of an edentulous patient deserves to be in the place of a professional who has his or her training in dentistry.
“That training can be superseded by specialty training in prosthodontics, and it even can be superseded beyond that by treatment by a group of specialists,” Cooper further explains. “A perfect example is the patient who has a small but resectable benign tumor that requires consultation with a pathologist and an oral surgeon, requires management and referral from their general dentist, and then requires a very elaborate or difficult denture construction by a prosthodontist.”
Cooper says that it would be a shame if such a patient were to be seen by an individual who is an expert in the fabrication of a denture but didn’t understand the details of all the other patient-care management. Some of the other issues are the co-morbidities that are associated with being edentulous.
“We now know that there are individuals who are edentulous who have oral stomatitis, or denture stomatitis; hyperplasia of their mucosa; oral biofilm on their dentures that contributes to the inflammatory situation in their mouth,” Cooper points out. “It might be that we find out that the inflammatory links of denture use are similar to the inflammatory links of periodontitis with systemic diseases. I think we need to put the general oral healthcare of patients, whether they have teeth or don’t have teeth, in the care of a well-trained professional, and that is the dentist.”
However, legislative bills (for example, in New York state) regarding denturism may move to the forefront as organized dentistry wrestles with how to provide dentures to those who need them, says David A. Felton, DDS, MS. He elaborates that there are approximately 33 million completely edentulous patients in the United States, not including Canada, with that many or more partially edentulous patients. There are only 4,000 trained prosthodontists in the United States, with no way that the specialty organization can treat all of those patients, he says.
Chapman says the issue regarding denturists is about standards of care or parameters of care. What are the minimal standards of care for making a denture that have been addressed by somebody that is overseeing training? Is there a general standard of care that a denturist association has? Chapman doesn’t believe so. Also, he points out the difference between treating a patient and applying a technique to replace the teeth in a person’s mouth.
“We just don’t have the manpower to be able to treat all of these edentulous and partially edentulous patients,” Felton says of his specialty organization. “That being said, what our role should be is to train the general practitioner at a sufficient level to meet the additional demand that this number of patients brings in the complete and partially edentulous arena to enable them to treat those patients as well.”
Felton says that perhaps neither prosthodontic specialty groups nor dental schools have done well in that regard. This, coupled with increasing demand for removable services, an increasing population, and the economic downturn that the economy has seen in the last couple of years, makes it very apparent that things such as denturism are on the forefront and receiving a lot of publicity and support at state legislatures, he suggests.
“The issue of access to care is important,” Cooper agrees. “If we find that there are communities of interest who need care and cannot find access to care under the current model—where one dentist makes a denture with the help of a dental laboratory technician—and the number of visits required to do this takes additional time and cost that are beyond the reach of this community of interest, then we have to think about ways in which a dentist or a prosthodontist can offer a better model for delivery of care.”
According to Ronald L. Rupp, DMD, good, sound, comprehensive continuing education experiences need to be bolstered and improved so that the current population of dentists in the country can better serve the population of partially and fully edentulous patients. Education in this area doesn’t just end with the dental school experience, he says.
“I think that not only in the predoctoral setting do we need to enhance the curriculum, but also in the postdoctoral educational experiences across the country where some choose to go into the prosthodontic specialty,” Rupp explains. “Then, beyond that, current practitioners in and across the country need further continuing education from not only face-to-face and Web-based educational programs, but also through articles published in peer-reviewed journals. It really is an ongoing experience of managing the expectations of the patient, of addressing the quality of life issues, and of better understanding the experience from the patient’s perspective.”
In North Carolina, a very high level of edentulism exists and has for a number of years, Felton says, emphasizing the need to do something to meet access to care issues for people who can’t afford a set of dentures that costs several thousand dollars. In the North Carolina and southeastern areas, the low-cost denture clinics have emerged to fulfill some of those needs, he says.
Notes Rick Workman, DMD, the founder and chief executive officer of Heartland Dental Care, access to care continues to be an ever increasing problem, particularly for indigent patients. To this end, he takes pride in the activities that Heartland undertakes to help meet some of the access to care needs in the communities it serves.
“While there are more and more dentists today who don’t provide any dentures, there are groups such as Affordable Dentures and Aspen Dental Care that are growing rapidly that offer the markets they serve very affordable denture care,” Workman observes. “These niches are being filled, and these needs are being handled by the different groups that are out there.”
Felton suggests that this might be a more appropriate model, where there are dentists supervising laboratory technicians who fabricate dentures for a patient in a very short period of time, rather than a laboratory technician being able to provide those services. “That being said, if denturism is, in fact, on the forefront and a growing growth industry, I think it’s incumbent upon our specialty area and the American College of Prosthodontists to take a leading role in helping to provide the training for those individuals to enable them to provide the best dentures that they can,” Felton believes.
The Inside Look From...
Issue after issue, the feature presentations in Inside Dentistry deliver coverage of the relevant and thought-provoking topics specifically affecting day-to-day practice within the dental profession. The publishers and staff could not bring the underlying concerns and trends surrounding these timely issues to the forefront without the insights shared by our knowledgeable and well-respected interviewees. For their collective generosity of time and perspectives, we extend our sincere gratitude.
Trends in Denture Materials, Fabrication, & Patient Expectations
Dentures today are not the dentures of our grandparents. Dentistry has made strides in improving materials, manufacturing, and processing techniques. There have even been strides made in terms of the techniques used to fit and prescribe dentures, as well as how such factors as occlusal planes are addressed.
“When we talk about state-of-the-art in dentistry, we don’t traditionally think of dentures, although there have been many significant improvements in dentures over the years,” comments Robert C. Vogel, DDS. “Some of the most significant improvements are in the materials but also in our knowledge of occlusal schemes, where we talk about lingualized occlusion to minimize the forces to the ridge and to increase the stability of the denture.”
“I believe that the market today does have the materials necessary to satisfy patient demands, whether for esthetics, comfort, or function,” notes Michael A. Gaglio, DDS, from Ivoclar Vivadent. “There’s still a need for improved materials, and that certainly is our goal, which is why we have a continued research and development initiative dedicated toward dentures.”
In general, Rick Workman, DMD, observes that the level of sophistication and the quality of care, stability of esthetics, and functionality of dentures are unbelievably superior to what they were when he graduated from dental school in 1980. However, he qualifies that observation by emphasizing that the industry can always and will do better.
“After all, we learned in dental school that dentures are not substitutes for teeth. They’re substitutes for no teeth,” Workman recalls.
Gaglio explains that today, more so than in the past, there is a need to develop better-wearing, better-fitting, and better esthetic materials specifically for dentures. As dentures become implant-supported/retained, the need for better wearing materials increases and becomes critical, he says.
“In the past, wearing a denture that might have slipped around in your mouth didn’t require a highly wear-resistant material, and having denture teeth that had good durability wasn’t as important as it is today,” Gaglio elaborates. “Today, because implant-supported/retained dentures are so stable in the mouth, they call for a stronger, more wear-resistant tooth.”
In addition, Gaglio explains that having implant attachments processed into the denture base material requires denture processing systems to be extremely accurate. If not, the attachments may not properly engage, and this may cause excess maintenance problems. Again, in the past, this was not as much of an issue because there were no attachments to deal with, and the soft tissue would “learn” to conform to the inaccuracies of denture base processing, he adds.
“The Ivocap injection processing system not only provides essential accuracy, but also provides an extremely dense surface, which is important because overdentures present a significant biological challenge due to the fact that denture base material remains in contact with the implant and its surrounding tissue for prolonged periods of time,” Gaglio points out. “Conventionally processed denture bases have significant micro-porosities that harbor bacteria and fungal material that can challenge the tissue around implants.”
Avery notes that there have been significant advancements in just the last few years alone, and he points to the precision processing of the Eclipse Resin System (by DENTSPLY) as an example of improved quality denture base technologies now available that provide improved fit and biocompatibility.
“These [from DENTSPLY and Ivoclar] are materials that give us less change, less fifth-dimensional change, and a more dense appliance with decreased breakage, as well as denture teeth that have been designed for the occlusal schemes that we’re working with now, such as lingualized occlusion,” comments Vogel.
Gaglio notes that patients today also are looking for better shades of teeth that are more natural-looking, as well as denture base materials that aren’t just pink, but that actually duplicate human tissue. Customized resins, he says, enable that type of esthetic result.
“People are more aware of today’s solutions through the media and people that they talk to, and they realize the importance of health and being able to maintain a proper diet,” Workman explains. “I don’t know what you’re going to do that’s going to improve your standard of living more than having the ability to have a stable dentition. Today, people realize that there are solutions and that they’re worth it.”
Gaglio says that while the technology in denture fabrication has not changed radically over the years, the digital revolution that dentistry overall is now undergoing might provide manufacturers with a new way to improve denture fabrication. He says he doesn’t think it’s out of the question to ponder whether someday we’ll use CAD/CAM technology for dentures.
“The fact of the matter is that in our profession, the clinical and laboratory procedures related to partial and full dentures really have not changed in many years. It would be wonderful to think that maybe in the near future that from industry, or out of research within dental schools, there might be new and better ways to replace missing teeth and restore the dentition,” ponders Ronald L. Rupp, DMD. “We’ve seen the advent of the CAD/CAM devices that can help the dentist create a crown chairside. Maybe there will be a way in the future to apply new and innovative technologies to removable prosthetics.”
Avery says that digital technology is improving the communication process between the clinician and the dental technician, who most often is not on site. Such advancements help the dental team to be more effective in providing improved esthetics, as well as understanding how things look in the patient’s mouth, he says.
“It’s hard to predict that at this point, but manufacturers are all striving for improvements in the technology of dentures,” Gaglio says. “Material properties have improved, but the technology itself has not dramatically changed in about 50 years.”
According to Avery, today there are numerous levels of price points available to patients. Large, multiple-site group practice organizations have been very successful at providing such care to patients in a streamlined manner and in a more cost-effective manner than traditional therapy.
Baby boomers have a tendency to have more expendable income than previous generations. They’re very concerned with their appearance and health and are willing to spend money for quality products and services related to both. That is lending itself to the fact that the higher-end sector of denture therapy—the higher-quality, the more characterized, customized treatment that does require more time and effort and, therefore, more cost—is a huge growth area for dentistry, explains Avery.
“I think that clinicians who position themselves and master the ability to deliver high levels of quality with very natural esthetics and laboratories that can support that have a very bright future,” Avery suggests. “There are always going to be various sectors of the economic strata that will need service at different price points, but I think the untapped market that really is in front of us represents a huge opportunity, and I don’t think there will be quite as much price pressure on the significant part of that market as you might imagine.”
Key to success in complete denture or removable partial denture therapy will be adequate education, whether for general dentists or possibly for denturists in the future, emphasizes Felton. Further, anything that can be done to enlighten the public about what a quality set of prostheses should and could be able to do for them would be very beneficial, he says, adding that people would not be accepting prostheses that are inadequate and instead would be demanding a higher quality of service.
“The latter would be predicated on our ability to work with our dental laboratory technicians,” Felton notes. “We need to improve our relationship between dentistry and the dental laboratory technology industry, as well as the commercial side of it, to enhance the overall quality of what can be provided for patients.”
To that end, Gaglio suggests that as with any market, it will be important to monitor population segments and changes in the economy. He says his company will continue to address the need for dentures and take an aggressive, innovative role to develop new products that address the projected demands for the edentulous patient treated with implants. Dentures with implants have altered the traditional denture “landscape” from prescription to delivery, he says, and will require new materials and techniques to better serve the dentist, technician, and of course, the patient.
“The good news is there are more and better high-end denture solutions available for patients, and we’re advancing the art of dentures all the time,” says Rick Workman, DMD, the founder and chief executive officer of Heartland Dental Care. “There also are solutions available for the less fortunate, and while there will always be work to do in that area, there are options.”
But, notes Vogel, the most important thing that dentists need to appreciate today is that overdentures are not to be compared to traditional dentures. Rather, he says the significant quality of life improvements that are seen by placing two or more implants under a denture can’t be overlooked.
“With the economy being what it is right now, where many patients might not be able to undergo a traditional, full-arched fixed case, an overdenture is—in most sit-uations—equally satisfying, as well as allowing the ability to go to a fixed case down the road,” Vogel says.
But, stresses Feine, in order to ensure that as many people as possible receive the benefits of this type of treatment, dental professionals could consider thinking “outside the box.” Doing so may inspire alternative care models offering more efficient, cost-effective approaches for the provision of implant-retained denture treatment.
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About the Contributors
David R. Avery, AAS, CDT
Director of Training and Education
Drake Precision Dental Laboratory
Charlotte, North Carolina
Robert Chapman, DMD
Chair, Prosthodontics & Operative Dentistry
Tufts University School of Dental Medicine
Lyndon F. Cooper, DDS, PhD
Chair and Graduate Program Director
Stallings Distinguished Professor of Dentistry
Department of Prosthodontics
University of North Carolina School of Dentistry
Chapel Hill, North Carolina
David A. Felton, DDS, MS
Professor, Department of Prosthodontics
University of North Carolina
Editor, Journal of Prosthodontics
Chapel Hill, North Carolina
Jocelyne Feine, DDS, MS, HDR
Professor, Faculty of Dentistry
Montréal, Québec, Canada
Michael A. Gaglio, DDS
Vice President of Marketing
Amherst, New York
Ronald L. Rupp, DMD
External Relations and Institutional Advancement
American Dental Education Association
Washington, District of Columbia
Robert C. Vogel, DDS
Palm Beach Gardens, Florida
Rick Workman, DMD
Founder and Chief Executive Officer
Heartland Dental Care